THE FUTURE: NURSE ANESTHETISTS OR M.D. ANESTHESIOLOGISTS?

Clinical Case for Discussion:  You are appointed Chairman of Anesthesia at an acute-care California community hospital.  The hospital administrator offers you a stipend to support the anesthesia care for his medical center, but it will be up to you to determine how to staff your operating rooms in the most cost-effective, safe, and efficient manner.  What do you do?

Discussion: What will the future of anesthesia manpower and staffing in California look like? Will you be supervising an infantry of nurse anesthetists?  Will you become the employee of another anesthesiologist who is your Medical Director?  Let’s stroke the crystal ball:

In the Rovenstine lecture published in the May 2006 issue of Anesthesiology, Mark Warner, M.D. (ASA President-elect for 2010) wrote, “Do we really need our best and brightest physicians to sedate and monitor patients undergoing cataract procedures when these patients have only an infinitesimal risk of developing a life-threatening problem intraoperatively?  Do we need them to deliver one-on-one care to healthy 20-year-olds who need general anesthetics for simple surgical procedures such as herniorrhaphies and peripheral orthopedic procedures? . . . There will be too few anesthesiologists, as well as insufficient funds to pay for such physician-intensive care. Further, there are no studies to suggest the need for physicians to personally deliver care to healthy patients undergoing minimally invasive procedures. As proven in a number of diverse practice models and in our intensive care units daily, physician oversight or supervision of well-trained sedation and critical care nurses, nurse anesthetists, and anesthesiologist assistants is a remarkably safe, efficient, and cost effective model for delivering care to appropriately selected patients. . . .  We have truly outstanding anesthesiologists who provide terrific care in intensive care units across this country.  None of them—not a single one of them—are assigned to provide one-on-one care to even the most critically ill patients in these units.”

On Friday March 20, 2009, the California Society of Anesthesiologists sponsored the first-ever meeting of the California anesthesia residency program directors, where representatives from all 11 anesthesia training programs in the state (UCSF, Stanford, UCLA, UCSD, San Diego Naval Hospital, UC Irvine, Harbor, Cedars-Sinai, USC, Loma Linda, and UC Davis) met at UCLA.  A portion of the meeting focused on likely changes in anesthetic practice over the next three decades, and how to best train the newest generation of anesthesiology residents to prepare for that future.

Michael Champeau, at that time the President of the California Society of Anesthesiologists and Adjunct Professor of Anesthesia at Stanford, attended the UCLA meeting.  According to Dr. Champeau, “the meeting attendees overwhelmingly felt that in order to remain economically viable in the changing health care world, anesthesiologists needed to expand the scope of services they provide beyond traditional one-on-one physician administered OR anesthesia to encompass the entire scope of perioperative medicine.”

Per Dr. Champeau, the program directors believed that the future of anesthesia will include a tiered spectrum of models of anesthesia care staffing ranging from a one-anesthesiologist-per-one-patient model for complex surgeries or complex patients down to one anesthesiologist supervising multiple nurse anesthetists (or Anesthesiologist’s Assistants, should they become licensed in California) for straightforward surgeries on healthy patients.  He emphasized that the CSA was certainly not promoting the expansion of the anesthesia care team model, but rather simply bringing the leaders of the anesthesia residency training programs in California together, listening to their thoughts about the future of the specialty, and drawing attention to the likely economic consequences of the anticipated changes in modes of practice.  The program directors believed that expertise in preoperative evaluation and optimization, risk stratification, operating room and perioperative team leadership, postoperative pain management and intensive care would be skills required for the anesthesiologist of the future.

While one-anesthesiologist-per-case staffing is currently the predominant model in California, Dr. Champeau went on to say that many groups might be only one entrepreneurial physician and one forward-thinking administrator away from changing to a tiered care model utilizing anesthesia care teams. Per data presented at the 2009 American Society of Anesthesia Conference on Practice Management, between 60-70% of anesthesia groups in the country are supported by a hospital stipend subsidy.  If utilizing the anesthesia care team model costs less than an all-physician model for anesthesia care, there may be increasing pressure in the upcoming years for utilizing anesthesia care teams.

In the U.S., solo M.D. practitioners deliver 35% of the anesthetics, anesthesia care teams with anesthesiologists medically directing Anesthesiologist Assistants or CRNAs deliver 55% of the anesthetics, and CRNAs in solo practice deliver 10% of the anesthetics.  The anesthesia care team model is less common in California, partly because the supply of anesthesiologists in California is sufficient to staff most cases without CRNAs.

The Kaiser system in California utilizes the anesthesia care team model.  David Newswanger, M.D., the Chairman of Anesthesia at Kaiser Santa Clara, told me the following key facts about his department:  His anesthesia staff includes 21 anesthesiologists in the general O.R., 7 anesthesiologists in the cardiac O.R., and 29 CRNA’s.  This staff covers 19 O.R.’s in three locations.  In the Ambulatory Surgery Center and in the Eye Center, 90% of the cases are done by CRNA’s supervised in a 4:1 or 3:1 CRNA:anesthesiologist ratio.  In the main O.R., anesthesiologists working alone cover 50% of the cases (more complex cases such as abdominal aortic aneurysms or thoracic cases), and supervised CRNA’s cover the other 50% of cases.  Kaiser has a system for assessing which patients are appropriate for an anesthesia care team and which need a solo anesthesiologist. A Preoperative Clinic team of 7 Nurse Practitioners screens 35% of pre-surgery patients, an MD anesthesiologist examines 5%, and medical assistants interview the remaining 60% by telephone and fill out standardized, preoperative questionnaires.

Back to our clinical case from the beginning of the column: (1) Would you hire both MDs and CRNAs, utilizing the anesthesia care team model? (2) Would you hire anesthesiologist employees and pay them the lowest salary you possibly could? (3) Would you assemble a team of anesthesiologists as equal partners?

Regarding the Kaiser CRNA anesthesia care team model, for a small hospital the start-up costs for staffing a pre-operative clinic and hiring enough anesthesiologists to cover all the night call may not leave any cost savings. According to Dr. Newswanger, in the capitated Kaiser model a CRNA is equivalent to 2/3 of an anesthesiologist when it comes to the economics of O.R. staffing.  That is, if he staffs his O.R.’s at a 3:1 ratio of CRNA:anesthesiologist, it’s a break-even point (1 + 3 X 2/3 = 3 M.D. equivalents for 3 O.R.s), whereas a 4:1 ratio is a money-saving staffing scenario (1 + 4 X 2/3 = 3 2/3 M.D. equivalents for 4 O.R.s).  In a fee-for-service practice, these numbers may be different, depending on the payer-mix of the patients.

Regarding the second option, a Medical Director anesthesiologist employing a team of lower-paid anesthesiologist employees, a central issue is that most anesthesiologists shun lower paying positions, and these hospital departments may be doomed to understaffing and high turnover.  The third option, assembling a team of equal-partner anesthesiologists, avoids these problems but may be less cost-effective.

There are specific concerns in staffing out-of-hospital surgery centers and office-based anesthetic locations.  I currently work in a one-anesthesiologist-per-patient private practice in which 15% of our cases are done in locations where there is only one operating room in a surgery center or a plastic surgery center.  In these settings, there is be no cost saving to having both an M.D. and a CRNA present to do the anesthetic, and a solo anesthesiologist-per-patient seems the likely staffing model. The question regarding the safety of replacing that solo anesthesiologist with a solo CRNA is a heated and separate issue that will not be discussed in this column.

The crystal ball is murky, and no one knows if the anesthesia care team model will turn out to be a dominant form of practice in California.  While the specifics of future anesthesia care staffing in California are uncertain, I am optimistic that the future will involve vigilant, high quality perioperative medicine, led by anesthesiologists.

Introducing …,  THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a legal mystery. Publication date September 9, 2014 by Pegasus Books.

The first four chapters are available for free at Amazon. Read them and you’ll be hooked! To reach the Amazon webpage, click on the book image below:

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Stanford professor Dr. Nico Antone leaves the wife he hates and the job he loves to return to Hibbing, Minnesota where he spent his childhood. He believes his son’s best chance to get accepted into a prestigious college is to graduate at the top of his class in this remote Midwestern town. His son becomes a small town hero and academic star, while Dr. Antone befriends Bobby Dylan, a deranged anesthetist who renamed and reinvented himself as a younger version of the iconic rock legend who grew up in Hibbing. An operating room death rocks their world, and Dr. Antone’s family and his relationship to Mr. Dylan are forever changed.

Equal parts legal thriller and medical thriller, The Doctor and Mr. Dylan examines the dark side of relationships between a doctor and his wife, a father and his son, and a man and his best friend. Set in a rural Northern Minnesota world reminiscent of the Coen brothers’ Fargo, The Doctor and Mr. Dylan details scenes of family crises, operating room mishaps, and courtroom confrontation, and concludes in a final twist that will leave readers questioning what is of value in the world we live in.

REVIEWS:

5.0 out of 5 stars The Doctor and Mr Dylan, March 3, 2015
By
prabha venugopal (chicago, il USA) – See all my reviews
Verified Purchase(What’s this?)
Gripping from the beginning to the end. Very well written, bringing to the forefront all the human emotions seen in an operating room spill over into real life. I cannot wait for Dr. Novak to wrote another book! As another physician in the same profession, my admiration for his book knows no limits.

Bang-Up Debut Novel, November 16, 2014

By Norm Goldman “Publisher & Editor of Bookpleasures”

This part legal and medical thriller is structured with a mixed bag of situations involving relationships, jealousy, evil, lies, courtroom drama, operating room mishaps as well as moments that engender conflicting and unexpected outcomes. Noteworthy is that as the suspense builds readers will become eager to uncover the truth involving a mishap concerning Nico and a surgical procedure that has unanticipated ramifications.

This is a bang-up debut from a writer who understands timing and is able to deliver hairpin turns, particularly involving the courtroom drama,that you would expect from a book of this genre.

TwinCities.com PIONEER PRESS Entertainment

by Mary Ann Grossman, Entertainment Editor, St. Paul Pioneer Press mgrossman@pioneerpress.com, January 4, 2015

“The Doctor & Mr. Dylan” by Rick Novak (Pegasus Books, $17.50)

Dr. Nico Antone doesn’t hide the fact he hates his wife, but he says he didn’t kill her during an operation. The authorities think otherwise and his trial is the riveting suspense in this novel that is part medical thriller, part legal thriller, part exploration of family relationships.

Nico is an anesthesiologist (as is the author) who leaves his wife, their plush life in California and his job at Stanford to move to his hometown of Hibbing so their son, Johnny, has a better chance of getting into a prestigious college. Johnny hates the idea of moving to a small, cold town, but he’s popular from the first day in school. Nico doesn’t do so well. He’s envied by Bobby, an anesthetist who’s jealous of the better-educated Nico. But it’s hard to take Bobby seriously, since he thinks he’s the young Bob Dylan and lives in the house where Bobby Zimmerman grew up. To complicate matters, Nico is attracted to the mother of the young woman his son is dating. When the two teens get in trouble, Nico’s furious, rich wife comes to Minnesota and needs an emergency operation that puts her on Nico’s operating table.

Novak grew up in Hibbing, where he worked in the iron ore mines and played on the U.S. Junior Men’s Curling championship teams of 1974 and ’75. After graduating from Carleton College, he earned a medical degree at the University of Chicago and spent 30-plus years at Stanford Hospital, where he was an associate professor of anesthesia and Deputy Chief of the Anesthesia Department. His courtroom scenes are based on his experiences as an expert witness.

The Physician’s Late-Night Reading List

Two Pritzker alums pen captivating tales

By Brooke E. O’Neill, University of Chicago Pritzker School of Medicine, editir, Medicine on the Midway Magazine

For most physicians, writing — patient notes, case histories, perhaps journal articles — is part of the job. But for anesthesiologist-novelist Rick Novak, MD’80, and neurosurgeon-memoirist Moris Senegor, MD’82, it’s a second career that consumes early morning hours long before they step into the OR.

Fans of John Grisham will find a kindred spirit in Novak, whose fast-paced medical thriller, The Doctor & Mr. Dylan (Pegasus Books, 2014), transports readers to rural Northern Minnesota, where an accomplished physician and a deranged anesthetist who thinks he’s rock legend Bob Dylan see their worlds collide in the most unexpected ways.

Delivering real-life twists and turns — and a love letter to the Bay Area — is Senegor’s Dogmeat: A Memoir of Love and Neurosurgery in San Francisco (Xlibris, 2014), a coming-of-age tale chronicling the author’s away rotation with renowned neurosurgeon Charles Wilson, MD, at the University of California, San Francisco. Brutally honest, it spares no details of a time Senegor, who also served as a resident under the University of Chicago’s famed neurosurgery chair Sean Mullan, MD, describes as “one of the biggest failures of my life.”

One a vividly imagined nail-biter, the other an intimate peek into the surgical suite, both books deliver an ample dose of intensity and drama.

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The Doctor and Mr. Dylan (Pegasus Books, 2014) by Rick Novak, MD’80

“I thought it was a novel way of killing someone,” said Rick Novak, deputy chief of anesthesiology at Stanford University, describing the imagined hospital death that was the genesis of his dark thriller The Doctor & Mr. Dylan. A huge Bob Dylan fan — the rock icon was born in Novak’s hometown of Hibbing, Minnesota, where the story takes place — he then dreamed up a possible culprit: a psychotic anesthetist who thinks he’s Dylan.

From there, the words flowed. “I would write whenever I was with my laptop and had a free moment: in mornings, in evenings, in gaps between cases,” said Novak, who also blogs about anesthesia topics. “I don’t sleep much.”

After finishing the manuscript — one year to write, another to edit — came the challenge of finding a publisher. “In anesthesia, I’m an expert,” Novak said. “In the literary world, I’m an unknown.” After 207 responses of “no, thanks” or no answer at all, he landed an agent. Two months later, she informed him that Pegasus Books had bought his debut novel.

“I started crying,” Novak admits. “I have a third grader and at the time the big word the class was learning was ‘perseverance.’ That was it exactly.”

Dr. Joseph Andresen, Editor, Santa Clara County Medical Association Medical Bulletin, from the January/February 2015 issue:

BOOK REVIEW “THE DOCTOR AND MR. DYLAN”

This past month, Dr. Rick Novak handed me a hardbound copy of his debut novel The Doctor and Mr. Dylan. Rick and I go way back. It was my first week of residency at Stanford when we first met. A newcomer to the operating room, all the smells and sounds were foreign to me despite my previous three years in the hospital as an internal medicine resident. Rick, a soft spoken Minnesotan at heart, in his second year of residency, took me under his wing and guided me through those first few bewildering months, sharing his experience and wisdom freely.

Fast-forward 30 years later. Dr. Rick Novak, a novel and mystery author? This was new to me as I sat down and opened the first page of The Doctor and Mr. Dylan. I have to admit that I didn’t know what to expect. Few books highlight a physician/anesthesiologist as a protagonist, and few books feature a SCCMA member as a physician/author. However, a medical-mystery theme novel wasn’t at the top of my must read list. With my 50-hour workweek, living and breathing medicine, imagining more emotional stress and drama was the furthest thing from my mind. However, three days later, as I turned the last page, and read the last few words. “life is a series of choices. I stuck my forefinger into the crook of the steering wheel, spun it hard to the left and …” This completed my 72-hour journey of and free moments I had, completely immersed in this story of life’s disappointments, human imperfections, and simple joys.

Rick, I can’t wait for your next book. Bravo!

Hibbingite writes twisted medical tale

HIBBING — Readers who are looking for a whodunit that will keep them up all night are in for a treat.

Hibbing native Rick Novak recently released his first book “The Doctor and Mr. Dylan,” a fiction set in Hibbing that merges anesthesia complications, a tumultuous marriage and the legend of Bob Dylan.

“The dialogue is sometimes funny, and there are lots of plot twists,” he said.

Novak said the book will not only entertain readers, but teach them about anesthesiology, Dylanology, the stressful race for elite college admission, and life on the Iron Range.

“The book is very conversational and streamlined,” he said. “I try to write as one would tell a story out loud.”

Novak said “The Doctor and Mr. Dylan” took him three years to perfect. He is currently working on his second book.

5.0 out of 5 stars I Sense We Have Another F.Scott Fitzgerald Emerging on the Literary Scene, December 1, 2014
By
Deann Brady (Sunnyvale, CA USA) – See all my reviews
(REAL NAME)
I found Rick Novak’s first novel, “The Doctor and Mr. Dylan,” a most exciting combination of biting sarcasm, mystery and daily activity spun with fresh new phrases that made me turn my ear back to listen to the literary cadence of his words again and again even though, on the other hand, I was anxious to turn the pages to see what would happen next. His brilliant handling of scenes is reminiscent of The Great Gatsby by F. Scott Fitzgerald. A compelling read!Deany Brady, author of “An Appalachian Childhood”

By

allan mishra

This review is from: The Doctor and Mr. Dylan (Kindle Edition)

Just finished Dr. Novak’s delightful novel. I sincerely enjoyed his honest take about the pressures and values that exist within California’s Silicon Valley. He also brought the North Country of Minnesota to life with memorable characters and a twisting, addictive plot. Buried beneath the fun and funny story is a deeper message about how to best care for your kids, your relationships and yourself. Very well written and highly recommended.

Learn more about Rick Novak’s fiction writing at rick novak.com by clicking on the picture below:

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