VA Safe Care

Anesthesiologists are now looking at what’s likely to be the beginning of the end, with a proposed rule to replace anesthesiologists with nurse anesthetists within the VA system.

This policy change is based on the idea of a physician shortage within the VA. According to Dr. Daniel J. Cole, M.D., the president of the American Society of Anesthesiologists, during the Press Briefing: Denouncing Dangerous VA Policy Change, of the “1108 anesthesiologist physician positions within the VA, only 7 are unfilled. When this number is corresponded to the shortage in the general sector of 56/1108, it is obvious there is no physician anesthesiologist shortage.”

Let me also put these numbers here, from the “When Seconds Count” campaign put on by the American Society of Anesthesiologists: “Physician anesthesiologists have 12,000 hours to 16,000 hours of clinical training, compared with nurse anesthetists, who have a median of 1,651 hours. A nursing education does not prepare nurse anesthetists for the many aspects of evaluating, diagnosing and treating a patient that can be required.”

Notice, the specific branch of medicine that is being undermined, anesthesiology. The others are nurse-midwifery, nurse primary care, and clinical nurse specialist. These are the perceived “low-hanging fruit” of medical care cost containment. Let’s see how this perception lines up with reality, at least with respect to anesthesiology as a specialty.

There are frequently articles about what an anesthesiologist does, coming from a baseline low understanding of what the job entails. The most common public answer to that question is “They put the patient to sleep and then go home.” So, understandably, from a public perspective, this is a very easy branch of medicine to cut care on. This lack of awareness (pun intended) is based on two categories: the depth of practice and how the anesthesiologist sees the patient.

When you as the anesthesiologist are completely alone, you have to get through the surgical case, the patient may be “crashing”, and it is frequently “all on you.” You are the last call. Through that type of training and responsibility, a different type of practitioner evolves. One that is both confident and cautious. One who is able to take swift action when needed, but who also realizes proper planning removes most needs for swift action. We know the ride depends solely on us, and therefore, a high degree of discernment evolves.

On a different vein, I have personally heard hundreds of cases of primary care being performed by an unlikely group: these same anesthesiologists. One by one by one, in every interaction, we let the patient know of anything unusual that happened during their surgery and that they should follow up with their general practitioner. We give specifics that their doctor can translate into further care and optimization of that patient’s health status.

Who else watches your diastolic blood pressure after giving a medication and puts together a picture of what your heart is able to do? Who else notices how just a little sedation causes your airway to obstruct and sends you back to your primary care physician for a sleep study, effectively extending your life by ten years? Who else notices you are on a double dose of synthroid because each was prescribed by different providers?

You can’t get a better witness for the disease process than someone who is watching your vital signs and how you respond to all of the different medications, minute by minute, for hours on end, under deranged physiologic and anatomic conditions. There is no other doctor who is looking at how you tick, and your level of health, closer than an anesthesiologist. They have seen end stage disease, end stage cancer, they have seen psychiatric issues, they have seen the spectrum of all that is body and mind disease, and what the physiologic limitations each individual patient has with those diseases.

To further state the actual value in this system, when a patient gets really sick in the operating room, the cardiologist and every specialist wants to hear from the anesthesiologist first. They take the surgeon’s and nurses’ report, but they are most concerned with what we saw throughout the case.

The strength of this type of understanding of medicine is the years of physical observation that serve to deepen the complex world of medicine already learned during the 8 training years after college. This is not something that is orated down, this is something that is experienced. Experience on top of a solid understanding of diagnosing and treating disease. As well, there is the ability to change the direction of treatment on a dime, when continued diagnostic skills are used along the way. Like the human being himself, the balance of health is an ever-moving target. We, the physician anesthesiologists, are the ones who hold a steady set point in the wildest of oceans. 

But we can’t do it alone.

There has been broad support of a team approach to anesthesia consisting of a physician, and most commonly nurse anesthetists, that provide care to a wide range of patients. The physician in this dynamic usually takes one highly sick patient and/or highly involved surgery, and then three more simple cases, with one nurse anesthetist assigned to each patient. One would assume most of the issues are with the sicker patient/more complex procedure. But oftentimes, it is within the “simple case” where life changing diagnoses are made. This model has been adopted as the primary model for anesthesia delivery in large hospitals, and has had a very successful history. I have worked within this model and can speak very highly of it’s ability to provide rapid, consistent care, with enough physician back-up to tackle the most challenging cases. It is a solid system.

Switching to nurse-only anesthesia care is not the safest, nor nearly the most efficient model for any system, much less for the current top hospital model. For all the reasons above, and also that the anesthesiologist sees the movie over the picture, we see the limits of health that are expressed as the body is challenged. This perspective is rarely possible when the depth of knowledge wasn’t challenged and the provider hadn’t been left to his own devices to push through discomfort to touch the borders of that which is living and that which is not, and to learn how to get back in spite of what the textbooks say.

By taking out every physician anesthesiologist from the VA, and to follow, every major hospital, a significant witness to a patient’s state of health would be lost. This witness would be replaced by a trained anesthesia provider, but one that fits a specific aspect of the anesthesia team approach, who was never meant to lead the operating room. We would be causing a great disservice to our patients, especially our sickest veteran patients. We would lose that “feeling” when something just isn’t right with the patient, having had access to these same experiences and somehow having crawled out on top. This is more than just about that hour or two on the operating room table, this is about one of the last group of doctors who really understands the whole patient. Tell your congressperson to keep physician anesthesiologists in the VA system, and protect your right to the highest level of care that is still available to you. Go to www.safevacare.org and make your voice heard to ultimately protect your very own choice.