Posts Tagged ‘Nurse anesthesia’

My patient and his wife didn’t understand that an anesthesiologist is a physician, despite his having been cared for by anesthesiologists during past procedures. They thought only CRNAs give anesthesia. What are we doing so wrong with our messaging, and how can we fix it?

One recent afternoon in the GI endoscopy suite (not my favorite place to work, but that’s a topic for another day), I walked up to the bedside of my next patient and introduced myself as I always do.

“Hi,” I said, holding up my name badge for the patient and his wife to see. “I’m Dr. Sibert.  I’m with the anesthesiology department and I’ll be looking after you today.”

The patient was an otherwise healthy man in his mid-30s, having his fifth endoscopy this year for a chronic though serious problem. My questions were few and he understood very well what was about to happen.

The consent process concluded, I asked if the couple had any other questions. The wife did.

“You’re a doctor when you’re not giving anesthesia?” she asked.

Wait. What?

 I’m seldom speechless, but this question took me by surprise. “Why yes,” I said, unsure how to respond.

“You’re a doctor, and you give anesthesia,” the patient’s wife said, making sure she heard correctly.  “Usually we’ve had CRNAs.”

“Yes,” I said. “I’m a doctor, and I give anesthesia all the time. I’m actually an MD who specializes in anesthesiology.”

The patient’s wife seemed slightly embarrassed but happy to acquire this new (to her) information — that doctors give anesthesia too, and that anesthesiology is a specialty practiced by physicians.

“So it must take a lot more training,” she mused. I confirmed that was true, and outlined the years of medical school, residency, and often fellowship training that we undertake to become fully qualified.

Since the patient and his wife seemed interested, I explained that there’s more to anesthesiology than the brief sedations he had experienced in the GI suite. I explained a little about my own specialty — thoracic anesthesia — and the challenge of ventilating each lung separately for lung operations. I went on to mention some of the other subspecialties including pediatric and cardiac anesthesiology.

At the mention of cardiac anesthesiology, a light bulb seemed to go off in the patient’s mind. “I think I had a cardiac anesthesiologist one time,” he said.

At that point, the GI team was ready to begin his procedure, so there was no more time to chat.  I gave the patient’s wife my business card with my title:  Clinical Professor of Anesthesiology and Perioperative Medicine. We headed to the procedure room. The circulating nurse and I hooked up his monitors; I started the propofol infusion. I watched his breathing and vital signs until the endoscopy was completed, turned the propofol off, and watched him wake up.

So many questions

This brief encounter left me with so many unanswered questions, and the unhappy feeling that no matter how much we may have done to try to explain the profession of anesthesiology to the lay public, clearly we’re not getting through.

This patient and his wife were not uneducated or economically disadvantaged. This was not their first encounter with the healthcare system; he had undergone four prior procedures at our teaching hospitals this year. If he received care from nurse anesthetists, they would have been under the medical direction of anesthesiologists. California is an opt-out state, but our health system does not permit nurse anesthetists to practice unsupervised.

How could the patient and his wife believe that all his prior anesthetic care had been given by nurse anesthetists?

Gender bias?

 My first hypothesis was that perhaps the patient had been taken care of by a mix of female anesthesiologists and female nurse anesthetists, all wearing the same nauseatingly pale green scrubs. It could be hard to tell one person from another — let alone remember who’s who — in the fast-moving assembly line of an outpatient GI endoscopy suite.

But when I looked up the patient’s previous records, that wasn’t the case at all.  Here’s the roster of anesthesia personnel for his four prior procedures, in chronologic order from first to most recent:

Female anesthesiologist and male nurse anesthetist

Male anesthesiologist, solo

Male anesthesiologist and male nurse anesthetist

Female anesthesiologist, solo

It turned out that the male anesthesiologist who worked solo was indeed a cardiac anesthesiologist, exactly as the patient recalled after our conversation jogged his memory.

So the total number of anesthesiologists who cared for this patient before I did was four — two women and two men — and the total number of nurse anesthetists was two, both men. Yet the impression he and his wife retained was that CRNAs gave him anesthesia. What can we make of that?

First names??

I’m sympathetic to the kindly impulse that can lead some of us to introduce ourselves by first names instead of using the title “Doctor”. We don’t want to seem elitist in the eyes of patients or staff. But is this a good idea?

There is evidence that reduction of “hierarchy” can improve patient safety by making it feel less threatening for anyone junior — whether in terms of age, professional rank, experience, or education — to question what is happening or about to happen. That’s the theory behind programs such as “Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS®)”.  Timothy Clapper, PhD, writing about the experience with TeamSTEPPS at Weill Cornell Medical College, states: “Healthcare workers may not speak up, even when it could make a difference for patient safety because they do not want to be wrong, are unsure, or do not want to hurt someone’s feelings.”

However, Dr. Clapper also notes: “From a communication standpoint, hierarchies are beneficial for healthcare teams, especially when time and clarity is an issue. Team members prefer to have a clear leader on their team. An effective leader operating in a suitable level of the hierarchy can quickly assign tasks and roles, especially during emergent cases to ensure task coverage and minimize delays. In healthcare systems, physicians regularly take on leadership roles and decision-making responsibilities.”

For physicians to assume those leadership roles, the key is for each person in the room to understand who among them is a physician and who is not.

If everyone on the team is introduced on a first-name basis, it may not be clear at all who is who, and which personnel are in leadership positions. This may be especially true when some people on the team are youthful trainees who rotate on and off teams in the course of their training. Is “Annabelle” an attending physician, a resident, a nurse, a nurse anesthetist, a physician assistant, a medical student, or a technician?  Confusion is almost inevitable when you can’t tell the players without a scorecard, and confusion can be lethal in a crisis.

First and last names??

Even when both first and last names are used, without the title “Doctor” in front of the name, a listener may not appreciate that the speaker is a physician.

The Editor of the ASA Monitor, Steven Shafer, MD, wrote a column in the August 2021 issue, explaining that he introduces himself to patients by saying, “Hello, I’m Steve Shafer. I’m the anesthesiologist who will be caring for you today.” He assumes that using the term “anesthesiologist” is sufficient to communicate the message that he is a physician with subspecialty training in anesthesiology.

This may work for many patients, but not all.  A recent survey by the American Medical Association found that 70% of patients recognized an anesthesiologist as a physician, 22% did not, and 8% were unsure. Several years ago, in the interest of truth in advertising, the ASA decided to champion the term “physician anesthesiologist”. Unfortunately, “physician anesthesiologist” is clumsy and difficult to say out loud without tripping over your own tongue. Does anyone use it in everyday conversation?

Which brings me back to my patient and his wife, and the fact that my self-introduction as “Dr. Sibert” created a moment of clarity that had been missing before.

What could have happened in the previous encounters?

Perhaps the anesthesiologists introduced themselves as Dr. Shafer does.

Perhaps the anesthesiologists who were supervising nurse anesthetists met the patient only briefly in the procedure room right before the case started, while the actual preop interviews were done by the CRNAs. This approach enables the anesthesiologist to duck into the room and quickly tick off the attestation boxes for preop assessment, assessment prior to induction, and presence at induction all at the same moment. However, in this scenario it’s unlikely that the patient will remember meeting the anesthesiologist at all.

Perhaps the term “CRNA” is just easier than “anesthesiologist” to say and remember.

Perhaps nurse anesthetists are simply better at promoting their brand.

We need to acknowledge a problem

Whatever the reason, I think we need to acknowledge that there is a problem. We can’t have it both ways:  abandoning formal titles and then complaining that no one knows we’re physicians. We can’t assume that our profession is going to get the respect it deserves if we’re reluctant to refer to ourselves as “Doctor”.

We can’t delegate the responsibility for doing the preoperative assessment to nurse anesthetists and then wonder why patients don’t know that an anesthesiologist was involved in their care.

We shouldn’t downplay our critical role in the operating room by introducing ourselves with our first names. Everyone on the team needs to know who the attending anesthesiologist is. This may be even more important if the attending anesthesiologist is young or female or both, and doesn’t necessarily look the part of a senior physician. During the time-out in the operating room, my standard response is, “I’m Dr. Sibert, with anesthesiology.”

With patients, I routinely introduce myself to patients as “Dr. Sibert”, trying as best I can to convey a smile behind my mask. I explain if I’m supervising a nurse anesthetist or a resident, or if I’ll be taking care of the patient by myself. I give out my business card liberally, making sure that my patients have a way to contact me after surgery if any issue should arise, and at the same time making it clear that I’m a board-certified physician who specializes in anesthesiology.

I have a hard time imagining Dr. Michael DeBakey in his prime ever introducing himself as “Mike”, and I won’t be saying, “Hi, I’m Karen,” anytime soon either.  All of us in anesthesiology have worked long years to become the physicians we are today. We need to own it, or else stop wondering why the public doesn’t know who we are.

(Author’s note:  This commentary and the accompanying illustration appeared first online in the November issue of the ASA Monitor on October 27, 2021.)

(This post chronicles the recent Los Angeles visit of ASA President Jeff Plagenhoef, MD, and his Grand Rounds presentation at USC. It originally appeared on the website of the California Society of Anesthesiologists. Above, Surgeon General Jerome Adams, MD, MPH, left, with Dr. Plagenhoef.)

“Who kicked whom off the anesthesia care team?” asked ASA President Jeff Plagenhoef, MD, FASA. Which professional association refuses to work amicably with the other, he inquired of his audience at the University of Southern California on September 15, as he delivered a powerful Grand Rounds address to the Department of Anesthesiology.

In his talk, “Professional Citizenship:  Responsibilities Shared by All Anesthesiologists”, Dr. Plagenhoef emphasized that physician anesthesiologists and the American Society of Anesthesiologists (ASA) fully support nurse anesthesia practice within the physician-led anesthesia care team. In his practice as Chair of the Department of Anesthesiology at Baylor Scott and White Hillcrest Medical Center in Waco, Texas, Dr. Plagenhoef works with nurse anesthetists and with certified anesthesiologist assistants (CAAs).

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Short-selling private practice

Today, January 29, is a remarkable day for me. I’m officially leaving private practice after almost 18 years, to return to academic medicine with a faculty position in a highly regarded California department of anesthesiology.

Why would I do that?

There are many positive reasons. I believe in the teaching mission of academic medicine:  to train the anesthesiologists of the future, and the scientists who will advance medical care. I enjoy teaching. The years I’ve spent at the head of the operating room table, anesthetizing patients every day, have given me a great deal of hands-on experience (and at least some wisdom) that I’m happy to pass along to the next generation.

But the other, more pragmatic reason is this. I’ve lost confidence in the ability of private-practice anesthesiology in California to survive in its prevalent form — physician-only, personally provided anesthesiology care.

MD-only:  A viable model?

California is an outlier among all other states in its ratio of physicians to non-physicians in the practice of clinical anesthesia. Nationally, there are slightly more non-physicians — including nurse anesthetists (about 47,000) and anesthesiologist assistants (about 1,700) — than physician anesthesiologists (about 46,000) in the workforce, according to 2015 National Provider Identifier (NPI) data.

But in California, there are about 5,500 physician anesthesiologists and only 1,500 nurse anesthetists in the workforce, while anesthesiologist assistants can’t yet be licensed here at all. Though some other states, chiefly in the western half of the U.S., also have more physicians than nurses in the anesthesia workforce, none tops California’s ratio of more than 3.5 to 1.

It’s hard to see how such a physician-skewed model of anesthesia care can continue to be financially viable, no matter how much affection I have for it. I genuinely love safeguarding my patients through anesthesia for complex surgical procedures, from beginning to end. But there’s no way that it makes sense for many of the tasks involved to be performed directly by a physician. If the Institute of Medicine advocates for nurses to practice “to the full extent of their education and training” in order to provide cost-effective care, it stands to reason that physicians ought to work at the top of their licenses too.

Many of the daily tasks involved in MD-only, personally-provided anesthesia care could and should be delegated to nurses, pharmacists, and technicians. Easy examples include starting IVs, drawing up medications, labeling syringes, and monitoring a patient’s blood pressure. Surgeons don’t perform these tasks during surgery, intensive care physicians don’t perform them in ICUs, and hospitalists don’t perform them on the inpatient wards. And we haven’t even mentioned other routine tasks such as changing the suction tubing on the anesthesia machine between cases — a duty that is well within the skill set of the OR clean-up crew. It makes no fiscal sense, in our cost-conscious time, for physicians to be performing these tasks personally.

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I admit, I was taken aback at the headline in the Houston Press:

GOING UNDER:  WHAT CAN HAPPEN IF YOUR ANESTHESIOLOGIST LEAVES THE ROOM DURING AN OPERATION

The curious reader is bound to wonder why the anesthesiologist would leave the operating room in the first place.

Of course, reporter Dianna Wray explains that in many hospitals, one physician anesthesiologist often supervises multiple cases staffed by nurse anesthetists. This model of care is called the “anesthesia care team“, and has a very long record of safe practice in nearly all major hospitals in the United States. Typically, the anesthesiologist makes rounds from one operating room to the next, checking on each case frequently, just as an internal medicine physician would round on patients in the hospital who are being monitored by their nurses.

Ms. Wray’s article narrates in detail what happened in several anesthesia cases where things went horribly wrong. She points out that the patients and families were not aware that the anesthesiologist would not be present during the entire case.

Complications can develop with patients on the ward, in the intensive care unit, or in the OR. In any medical setting, the nurse’s job is to recognize the problem in time to call for help, so that the physician can respond and the patient can be treated successfully. Sometimes, the call for help may not come in time for successful resuscitation. The results can be tragic — cardiac arrest, brain damage, even death. Hospitals track “Failure to Rescue” events that cause adverse patient outcomes as a Joint Commission and CMS standard for measuring quality in nursing care.

The fact is — anesthesia is dangerous. We have made huge strides in developing safer drugs and better monitoring techniques. But going under anesthesia — losing consciousness from the drugs we give — is really the same thing as inducing coma. Most anesthesia drugs have the potential to depress breathing, lower blood pressure, and decrease the function of the heart. Even regional anesthesia, using proven techniques such as spinal and epidural blocks, can cause major complications.

I can verify that even the most routine procedure — under sedation, regional block, or general anesthesia — has the potential to evolve into a crisis. Some days are completely routine, and some days I find I need every scrap of medical knowledge and experience I can bring to the problems my patients face.

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A Call for Civility

Why can’t physician anesthesiologists, nurse anesthetists, and anesthesiologist assistants just get along?

American anesthesiology reached a significant milestone last year, though many of us probably missed it at the time.

In February, 2014, the number of nurse anesthetists in the United States for the first time exceeded the number of physician anesthesiologists. Not only are there more nurses than physicians in the field of anesthesia today, the number of nurses entering the field is growing at a faster rate than the number of physicians. Since December, 2012, the number of nurse anesthetists has grown by 12.1 percent compared to 5.8 percent for physician anesthesiologists.

The numbers—about 46,600 nurse anesthetists and 45,700 physician anesthesiologists—reported in the National Provider Identifier (NPI) dataset for January, 2015, probably understate the growing disparity. Today, more and more physicians are leaving the front lines of medicine, many obtaining additional qualifications such as MBA degrees and embarking on new careers in hospital administration or business.

Physician anesthesiologists can expect that fewer of us every year will continue to work in the model of personally providing anesthesia care to individual patients. Clinical practice is likely to skew even more toward the anesthesia care team model, already dominant in every part of the US except the west coast, with supervision of nurse anesthetists and anesthesiologist assistants.

So why does the level of animosity between physician anesthesiologists and nurse anesthetists seem to be getting worse, even as the care team gains greater prominence? Does the anonymity of the Internet bring out the worst in everyone and make civilized discourse impossible?

Anesthesiologist assistants (AAs), of course, are to anesthesiologists what physician assistants are to physicians in other specialties. They are under the jurisdiction of medical boards, not of nursing boards, and are firm supporters of anesthesiologists. In contrast, the website of the American Association of Nurse Anesthetists (AANA) states that nurse anesthetists “collaborate with other members of a patient’s healthcare team: surgeons, obstetricians, endoscopists, podiatrists, pain specialists”—a list which pointedly excludes physician anesthesiologists.

Perhaps increasing downward pressure on payments and tough competition among hospitals are worsening the strain on anesthesia practitioners of all stripes. But in an era where healthcare professionals are faced with onerous new rules and regulations on a daily basis, and report alarming levels of burnout, does it make sense for groups with so much in common to be permanently at odds? Wouldn’t they do better as allies? In the field of anesthesia, why can’t physicians, nurses, and AAs just get along?

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