Tag anesthesia care team

ANESTHESIOLOGISTS COVERING THREE OR FOUR OPERATING ROOMS AT ONCE CAN INCREASE RISKS 

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THE ANESTHESIA CONSULTANT
THE ANESTHESIA CONSULTANT
Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com
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JAMA Surgery published the study “Association of Anesthesiologist Staffing Ratio With Surgical Patient Morbidity and Mortality” on July 22, 2022. This was a landmark paper on the topic of anesthesiologist:CRNA staffing ratios, which documented that having physician anesthesiologists direct three or four operating rooms simultaneously for major noncardiac inpatient surgical procedures increased the 30-day risks of patient morbidity and mortality. The senior author was Sachin Kheterpal, MD, MBA, of the Department of Anesthesiology at the University of Michigan Medical School. The data was from a retrospective matched cohort study of major noncardiac inpatient surgical procedures performed from January 1, 2010, to October 31, 2017, and was conducted in 23 academic and private hospitals in the United States. 

The University of Michigan paper stated, “this study primarily analyzed physician-CRNA teams, the dominant practice model in US anesthesiology.” The physician-CRNA team, otherwise known as an anesthesia care team, is a model strongly supported by the American Society of Anesthesiologists.  The anesthesia care team is a system in which one anesthesiologist covers one, two, three, or four separate operating rooms, each room staffed by a Certified Registered Nurse Anesthetist (CRNA) or an anesthesia assistant (AA). From a very large initial data set of 3,624,399 operations, the University of Michigan authors calculated the staffing ratio of physician anesthesiologist: CRNA for each operation. The following types of cases were excluded: anesthesia care personally performed by a physician anesthesiologist working alone; anesthesia care which involved an anesthesia assistant; anesthesia care involving an anesthesia resident; and anesthesia care that occurred overnight, during weekends, or on holidays. After these exclusions were applied, the data set consisted of 866,453 operations, in which 1960 anesthesiologists provided care in 23 different hospitals.

Data was divided into four groups:

  • Group 1: one anesthesiologist covering one operation (48,555 patients)
  • Group 1-2 (reference group): one anesthesiologist covering more than one to no more than two overlapping operations (247,057 patients)
  • Group 2-3: one anesthesiologist covering more than two to no more than three overlapping operations (216,193 patients)
  • Group 3-4: one anesthesiologist covering more than three to no more than four overlapping operations (67,010 patients)

The four groups were studied regarding 30-day morbidity and mortality outcome data. The morbidities included cardiac, respiratory, gastrointestinal, urinary, bleeding, and infectious complications. Overall, morbidity and mortality occurred after 30,026 operations (5.19%).

The results:

Compared with patients in group 1-2, those in group 2-3 had a 4% relative increase in mortality and morbidity (5.06% vs 5.25%; P = .02). 

Compared with patients in group 1-2, those in group in group 3-4 had a 14% increase in risk-adjusted mortality and morbidity (5.06% vs 5.75%; P < .001).

The paper stated, “When 100,000 operations, which is typical annually for a major medical center, are considered, the increase in risk from 5.06% to 5.75% that we observed would translate to an additional 690 operations with adverse outcomes,” and “increased overlapping anesthesiologist coverage beyond 1 to 2 operations was associated with an increased risk of surgical patient morbidity and 30-day mortality. Because 313 million surgical procedures are performed worldwide each year, any small individual improvements in outcome can have major repercussions for public health. These results complement previous studies that have shown improved 30-day mortality and morbidity rates after complications when anesthesiologists directed anesthesia care.”

The results of this study may be criticized because the data was retrospective, but it’s unlikely any prospective study will ever be done randomizing major noncardiac inpatient surgeries to anesthesiologist:CRNA ratios of 1:1, 1:2, 1:3, and 1:4. The adoption of Electronic Medical Records (EMRs) brought on the arrival of Big Data such as in this paper, in which a Herculean total of over 3.6 million charts were studied. An EMR enables physicians to study trends and outcome data in ways that were previously impossible. Does the data from the University of Michigan study support the fact that decreased staffing by physician anesthesiologists in major noncardiac inpatient surgical procedures is associated with increased 30-day morbidity and mortality? Yes, it does. Will this conclusion change the future practice of anesthesiology? Perhaps, but probably not. Why not? Let’s examine the most likely reasons behind the increased anesthesiologist:CRNA staffing ratios:

  1. There may be an inadequate supply of physician anesthesiologists to staff all major noncardiac inpatient surgical procedures at anesthesiologist:CRNA ratios of 1:1 or 1:2. There were 31,130 anesthesiologists in the United States in 2021, and more than 55,000 CRNAs in the United States. There were approximately 21 million surgeries per year in the United States in 2014.   The ratio of the number of surgeries compared to the number of anesthesiologists (21,000,000/31,130) equals 675 surgeries per anesthesiologist, a busy caseload. But the geographical distribution of where anesthesiologists live is not random, with populations of MD anesthesiologists concentrated in urban and suburban areas, and populations of MD anesthesiologists less concentrated in rural areas. Some locations have an inadequate census of physician anesthesiologists to staff every case as solo practitioners or at an anesthesiologist:CRNA ratio of 1:1 or 1:2. 
  2. A higher anesthesiologist:CRNA ratio may be a strategy to decrease the cost of anesthesia care. This issue was examined in detail in the American Society of Anesthesiologists Monitor.  In this study, the reported average yearly salary for a CRNA was $202,000, and they worked 40 hours per week. The reported average yearly salary for a private practice anesthesiologist was $440,000, and they worked 55 hours per week.  Cost-analysis showed that with adequate numbers of CRNAs to staff anesthesia care teams and to cover breaks for working CRNAs, the anesthesiologist:CRNA ratios of 1:2 and 1:3 were actually more expensive than running the rooms with a solo anesthesiologist in each room. An anesthesiologist:CRNA ratio of 1:4 was only marginally (< 10%) less costly than running the rooms with a solo anesthesiologist in each room. 
Figure 3: 7 a.m. to 5 p.m. with break staff included. Because one needs 1.25 CRNAs per site to cover the 10-hour shifts, the cost savings for anesthesia care team model is further reduced. Anesthesia care team costs are compared to physician-only (MD-only). Spikes in costs are when the number of sites cannot be divided by the staffing ratio. 

3. A high anesthesiologist:CRNA ratio may increase the income per anesthesiologist. When one anesthesiologist directs multiple CRNAs in multiple operating rooms, that solitary physician anesthesiologist can increase his billing for the day. “Medical direction of 2-4 concurrent anesthesia procedures: When two to four concurrent anesthesia procedures are medically directed, report with modifier QK. Services submitted with modifier QK will be reimbursed at 50% of the applicable fee.” 

Medical direction of four CRNAs –> the anesthesiologist can bill 50% of Physician Allowed Amount and 50% of CRNA Allowed Amount.

With four operating rooms directed by one anesthesiologist, the 1st, 2nd, 3rd, and 4th operating rooms can each be billed at 50% of the anesthesia fee. Billing for four rooms simultaneously can increase the income for that solitary anesthesiologist over that time period. An anesthesiologist working alone, without CRNAs, can only attend to one patient, and can only bill services for a single patient. An analogy is a taxicab or Uber driver who can only bill for one ride at a time. The only way for a solo taxi driver or Uber driver to earn more money is to give more rides, and the only way for a solo anesthesiologist to earn more money is to do more cases for more hours of time.

The senior author of the University of Michigan study was Sachin Kheterpal, MD, MBA from the Department of Anesthesiology, yet the study was published in a surgical journal, JAMA Surgery, rather than an anesthesiology journal.Did anesthesiology journals reject the opportunity to publish the study? I don’t know. It’s pertinent that surgeons care greatly about the outcomes of surgeries they perform, and surgeons are less concerned with the economics of anesthesia staffing. Surgeons reading this study will no doubt conclude that an anesthesia group covering major noncardiac inpatient surgical cases with 1:3 or 1:4 anesthesiologist:CRNA staffing ratios are exposing their patients to an increased risk of morbidity and mortality.

Will this study change the anesthesiologist:CRNA staffing ratios in the future? My gut impression is that it will not. Anesthesiologists do not routinely read JAMA Surgery and may be quick to dismiss the findings. Surgeons may complain to their anesthesia colleagues that they do not want 1:3 or 1:4 anesthesiologist:CRNA staffing ratios for their major noncardiac inpatient surgical patients, but it’s unlikely they will have any power to enact change if the anesthesiologists don’t want to change. Why would anesthesiologists not move away from 1:3 or 1:4 anesthesiologist:CRNA staffing ratios? See the three reasons above: an inadequate supply of physician anesthesiologists; the quest to decrease anesthesia costs; and the goal of maximizing anesthesiologist income by directing 3 or 4 operating rooms at the same time.

I asked the anesthesia chairman of a large health-maintenance organization (HMO) how his group assigned anesthesia staffing, and his reply was that they used tiered staffing. A demanding case such as an open-heart surgery or a craniotomy was staffed by a solo physician anesthesiologist. In contrast, simple low-risk cases such as bunion repairs or carpal tunnel repairs on healthy patients were staffed by the maximal anesthesiologist:CRNA ratio of 1:4. The spectrum of remaining cases fell between these two extremes, and the anesthesiologist:CRNA ratio was assigned according to the difficulty and the risk of the anesthetic.

As a patient, how do you feel about all this? Would you be concerned if you were to be anesthetized by an anesthesia care team utilizing a 1:3 or 1:4 anesthesiologist:CRNA staffing ratio? In the University of Michigan study, if your surgery was a major noncardiac inpatient surgery during daytime hours, the data showed that your anesthesia team is putting you at increased risk for 30-day morbidity and mortality. The University of Michigan study only examined inpatient surgeries, so if you’re having outpatient ambulatory surgery, this study does not apply to your surgery. In 2014, outpatient surgery outnumbered inpatient surgery by 11,474,800 to 10,303,000. But if you or your family member are scheduled for major noncardiac inpatient surgery, it’s important to ask the question of what the anesthesiologist:CRNA staffing ratio will be while you or your family member are asleep, and how much of the time will your anesthesiologist be in the operating room.

If I was to be cared for by an anesthesiologist:CRNA ratio of 1:3 or 1:4 for a major noncardiac inpatient surgery during daytime hours, I would raise an objection before the anesthetic started, and I would direct my objection at both the attending anesthesiologist and the attending surgeon. Based on the data from the University of Michigan study, I would request an anesthesiologist:CRNA ratio of no higher than 1:2, or I would request a solo anesthesiologist to attend to me.

I’d suggest you do the same.

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The most popular posts for laypeople on The Anesthesia Consultant include:
How Long Will It Take To Wake Up From General Anesthesia?
Why Did Take Me So Long To Wake From General Anesthesia?
Will I Have a Breathing Tube During Anesthesia?
What Are the Common Anesthesia Medications?
How Safe is Anesthesia in the 21st Century?
Will I Be Nauseated After General Anesthesia?
What Are the Anesthesia Risks For Children?

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:
10 Trends for the Future of Anesthesia
Should You Cancel Anesthesia for a Potassium Level of 3.6?
12 Important Things to Know as You Near the End of Your Anesthesia Training
Should You Cancel Surgery For a Blood Pressure = 170/99?
Advice For Passing the Anesthesia Oral Board Exams
What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM

WILL CRNAs REPLACE MD ANESTHESIOLOGISTS?

THE ANESTHESIA CONSULTANT Leave a comment
THE ANESTHESIA CONSULTANT
THE ANESTHESIA CONSULTANT
Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com
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Who is responsible for your anesthetic? A doctor or a nurse? On March 28, 2021 the anesthesia world in the United States was rocked by the headline: “Wisconsin Hospital Replaces All Anesthesiologists With CRNAs.“  

The hospital was Watertown Regional Medical Center, located in Watertown, Wisconsin,  population 23,861, midway between Milwaukee and Madison. The medical center previously had an anesthesia staff that included both MDs and CRNAs (Certified Registered Nurse Anesthetists).  Why did this change happen? The article didn’t say. The article did say that “Envision, a large medical staffing agency that works with the hospital . . . will oversee the anesthesiology team. A quote from the Medscape article read: “Adam Dachman, MD, a surgeon at the hospital, speaking for himself, said he has no problem using nurse anesthetists. (He said) ‘It’s a misconception that physicians are required to administer anesthesia.’” 

Is this a watershed moment for the profession of physician anesthesiologists? Are CRNAs going to replace MD anesthesiologists all over America, changing the profession forever?

In a word, no. 

Will certified registered nurse anesthetists (CRNAs) will be major factor in anesthesia care in the 21st century? Yes. See this link. There are roles for both CRNAs and physician anesthesiologists in the 21st century. 

Let’s step back and look at healthcare practitioners from the view of a patient. Let’s say you’re a patient, and you enter a medical clinic for a checkup. An individual who is not a doctor interviews you, it’s usually quite clear by their nametag and by their verbal introduction whether they are a physician, a nurse, a physician assistant, or a nurse practitioner. Each of these job titles has a different educational background, a different duration of training, and a differing level of autonomy and responsibility. If a physician assistant or a nurse practitioner presents themselves as your healthcare provider in a clinic, you realize you are not being attended to by a physician.

When you enter a hospital or surgery center for a surgery and an anesthesia professional approaches you prior to your surgery, that professional could be a physician anesthesiologist, a Certified Registered Nurse Anesthetist, or an Anesthesia Assistant (AA). Each of these job titles has a different educational background, a different duration of training, and a differing level of autonomy and responsibility. If a CRNA presents themselves as the sole anesthesia professional responsible for evaluating you and making the anesthesia plan and carrying out all the anesthesia care,  you realize you’re not being attended to by a physician.

Are CRNAs and anesthesiologists equals? No, they are not. The difference in training is profound. CRNAs are registered nurses with a minimum of one year experience as a critical care nurse followed by, on the average, an anesthesia training period of three years. Anesthesiologists are medical doctors, and their training of four years of medical school followed by a minimum of four years of anesthesia residency following makes them specialists in all aspects of anesthesia care and perioperative medicine.

Physician anesthesiologists frequently employ CRNAs to assist them in the anesthesia care team model. In this model, an MD anesthesiologist supervises up to four CRNAs who work in up to four different operating rooms simultaneously. The responsibility for the anesthesia care in this model resides with the supervising MD anesthesiologist. 

The American Society of Anesthesiologists STATEMENT ON THE ANESTHESIA CARE TEAM “Anesthesiology is the practice of medicine including, but not limited to, preoperative patient evaluation, anesthetic planning, intraoperative and postoperative care and the management of systems and personnel that support these activities. . . . This care is personally provided by or directed by the anesthesiologist.”

Governors in 19 primarily Western states (Wisconsin, Arizona, Oklahoma, Iowa, Nebraska, Idaho, Minnesota, New Hampshire, New Mexico, Kansas, North Dakota, Washington, Alaska, Oregon, Montana, South Dakota, California, Colorado, and Kentucky) have signed legislation allowing CRNAs to opt out of physician supervision and practice anesthesiology alone. The primary motivation for this change was the fact that hospitals in rural communities had inadequate numbers of physician anesthesiologists. Empowering CRNAs to work alone made surgery more accessible to patients in these rural areas. I have no personal connection to or communication with the Watertown Regional Medical Center, but a small community like the one in Watertown Wisconsin likely was unable to recruit or retain a full lineup of MD anesthesiologists, so they were forced to staff with CRNAs. The Watertown Regional Medical Center website, under “Find a Doctor,” as of April 25, 2021 listed 3 MDs and 10 CRNAs.  

Is there any data that CRNA anesthesia care is less safe than MD anesthesia care?  There is. Doctor J H Silber’s landmark study from the University of Pennsylvania documented that both 30-day mortality and failure-to-rescue rates were lower when anesthesia care was supervised by anesthesiologists, as opposed to anesthesia care by unsupervised nurse anesthetists. This study has been widely discussed. The CRNA community dismissed the study’s conclusions, citing that the Silber study was a retrospective study. 

An anesthesia blog, Great Z’s, recently posted a column titled CRNAs Take Over America. The column said, “the anesthesia care team model will be the end of physician anesthesiologists. With the ACT model, anesthesiologists’ roles become more like physician assistants. We’re outside the operating rooms, dealing with preop history taking, starting IV’s, making sure the patients are ready for their surgeries. Meanwhile, the CRNAs are the ones that are administering the anesthesia. They are the ones the surgeons will interact with 90% of the time. Our interactions with surgeons diminish to the point where they feel the CRNAs are doing all the work and no physician anesthesiologist is needed. This makes the hospital administration’s decision to save money by firing all the anesthesiologists that much easier and less controversial with the staff.” 

I disagree that MD anesthesiologists will be pushed out the doors nationwide. Easy anesthetic cases can be done by either MDs or CRNAs, but complex cases (open heart surgery, brain surgery, neonatal surgery, surgery on patients with multiple medical comorbidities) will nearly always require physician anesthesiologists. I believe surgeons will support the role of physician anesthesiologists in their operating rooms. Surgeons have no incentive to replace physician anesthesiologists with CRNAs. Patients have no incentive to replace physician anesthesiologists with CRNAs. Would CRNA anesthesia care be less expensive? There is a paucity of data to support that, with only one study to date, published in a nursing journal (Journal of Nursing Economics) which concluded that, “CRNAs acting as the sole anesthesia provider cost 25 percent less than the second lowest cost model.” 

In California where I live and work, Governor Arnold Schwarzenegger signed the independent practice for CRNAs into law in 2009. California physician anesthesiologists were angry and concerned about the legislation change at the time, but in the 12+ years since 2009, the penetration of unsupervised CRNA practice in California was been minimal. The traditional old models of physician-only anesthesia or the anesthesia care team are still the dominant modes of practice in California. 

One threat that remains troubling is the specter that national staffing companies (see the Watertown story above) may force out MDs and hire predominantly CRNAs, collect the standard anesthesia fees for each case, pay the CRNAs less than they paid MD anesthesiologists, and therefore increase profit to the shareholders of the parent company. What can anesthesiologists do about this problem? Don’t sell your anesthesia practice to a national company. But if your hospital CEO makes an exclusive contract with such a company, it’s possible you could be forced out without any choice.

CRNAs will have a significant role in American healthcare in the future. The most significant role will be played with an MD anesthesiologist at their right hand supervising them. Non-supervised CRNAs will be found mainly at rural hospitals. I don’t see a significant number of unsupervised CRNAs working in Palo Alto, Manhattan, or Boston anytime soon.

The future for physician anesthesiologists still looks bright.

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The most popular posts for laypeople on The Anesthesia Consultant include:
How Long Will It Take To Wake Up From General Anesthesia?
Why Did Take Me So Long To Wake From General Anesthesia?
Will I Have a Breathing Tube During Anesthesia?
What Are the Common Anesthesia Medications?
How Safe is Anesthesia in the 21st Century?
Will I Be Nauseated After General Anesthesia?
What Are the Anesthesia Risks For Children?

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:
10 Trends for the Future of Anesthesia
Should You Cancel Anesthesia for a Potassium Level of 3.6?
12 Important Things to Know as You Near the End of Your Anesthesia Training
Should You Cancel Surgery For a Blood Pressure = 170/99?
Advice For Passing the Anesthesia Oral Board Exams
What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM.

THE TWO LAWS OF ANESTHESIA (ACCORDING TO SURGEONS)

THE ANESTHESIA CONSULTANT Leave a comment
THE ANESTHESIA CONSULTANT
THE ANESTHESIA CONSULTANT
Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com
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There are Two Laws of Anesthesia, according to surgeon lore. They are:

  1. The patient must not move.
  2. The patient must wake up (when the surgery is over).

Surgeons work with physician anesthesiologists, with certified nurse anesthetists (CRNAs), or with an anesthesia care team that includes both physician anesthesiologists and CRNAs. Most surgeons’ comprehension of what anesthesiologists are doing is limited. Most surgery residencies have zero months of anesthesia training out of their sixty months of total residency. No matter who supplies the anesthesia services, to our surgical colleagues the critical requirements of anesthesia include 1. and 2. above. 

Period.

Physician anesthesiologists finish medical school and complete at a minimum four additional years of training. Surgeons finish medical school and complete at a minimum five additional years of training. There’s not much difference there. Anesthesiologists typically spend 90+% of their working hours in the operating room. A busy surgeon will spend 50% of their time in the operating room, and the other 50% in preoperative clinic, postoperative clinic, or rounding on patients in the hospital. Anesthesiologists win the tally for most operating room hours per week. Anesthesiologists take care of a patient’s heart, lungs, brain, and kidney function before, during, and after surgery. Surgeons perform a specific operation on one organ system, e.g. heart surgeons operate on the heart, orthopedic surgeons operate on a bone or a joint, and ear surgeons operate on ears.

Yet in all the surgical specialties, Two Laws describe the surgeons’ lofty expectations of anesthesia professionals:

  1. The patient must not move.
  2. The patient must wake up (when the surgery is over).

Physician anesthesiologists learn to perform anesthesia for all types of surgery, including cardiac, vascular, trauma, neurosurgery, pediatrics, eye, ear nose and throat, urology, and obstetrics. Physician anesthesiologists attend to patients of all ages, from newborns to centenarians. Physician anesthesiologists develop an extensive understanding of physiology as well as the pharmacology of hundreds of medications. Physician anesthesiologists regularly insert breathing tubes, venous catheters, arterial catheters, and stomach tubes, and inject regional anesthetic blocks into the spinal fluid, the epidural space, and learn nerve blocks of every major peripheral nerve.

Yet to our surgical colleagues, Two Laws describe an excellent anesthesiologist’s work:

  1. The patient must not move.
  2. The patient must wake up (when the surgery is over).

Let’s examine the Two Laws:

  1. The patient must not move. This Law is important because a surgeon must not be distracted by motion within the surgical field. If a patient coughs or bucks on the breathing tube, movement will occur. The surgeon must stop, sometimes for 60 seconds or more, while the anesthesiologist administers additional drugs to the patient. During these 60 seconds, it’s important that the surgeon sighs, crosses his or her arms, or otherwise expresses what a major inconvenience this loss of 60 seconds has been. Has a patient ever been harmed by an episode of brief movement? In the overwhelming majority of surgeries there is no harm whatsoever. In a perfect anesthesia world, patients will not move. But in the majority of anesthetics the patient is not chemically paralyzed, and it is possible for movement to occur. An overly deep level of anesthesia will help prevent movement, but has the adverse consequence of requiring a longer time to wake the patient at the end of the surgery. Which brings us to Law #2:
  2. The patient must wake up. When the surgeon finishes suturing the skin incision and  concludes the surgery, he or she will remove their gloves and gown and wait for the anesthesiologist to wake the patient. Modern anesthetics wear off quickly, and for most surgeries the duration of time from the end of surgery to the patient waking and talking is approximately 10 – 15 minutes. But these are minutes during which the surgeon must watch and wait. These are minutes during which the surgeon’s valuable time is ticking by, and seemingly wasted. In the overwhelming majority of surgeries, anesthesiologists successfully wake the patient and remove the breathing tube. At this time the surgeon can leave the operating room to meet with the patient’s family and discuss the successful operation. None of this could happen if the anesthesiologist was not competent with Law #2. 

If you’re a medical student considering a surgical specialty, it’s important you understand the Two Laws. If you become an anesthesiologist or a surgeon, you will be on one side or the other of the Two Laws. 

If you’re a patient, consider that it’s your surgeon’s job to cut and cure while it’s your anesthesiologist’s job to keep you from moving and to wake you up. Of course, your vigilant physician anesthesiologist will also assure that you’re safe, asleep, and unaware. Your vigilant physician anesthesiologist will also assure that you’re as stable and as healthy as possible after surgery. Trust your anesthesiologist  and realize that while these Two Laws come from the lips of surgeons, the genesis of the Two Laws perhaps occurred with a tongue in cheek. I’ve had excellent relationships with hundreds of surgeons over decades, and despite these Two Laws, the majority of surgeons are wonderful doctors and healers who are not condescending toward their anesthesia colleagues whatsoever.

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The most popular posts for laypeople on The Anesthesia Consultant include:
How Long Will It Take To Wake Up From General Anesthesia?
Why Did Take Me So Long To Wake From General Anesthesia?
Will I Have a Breathing Tube During Anesthesia?
What Are the Common Anesthesia Medications?
How Safe is Anesthesia in the 21st Century?
Will I Be Nauseated After General Anesthesia?
What Are the Anesthesia Risks For Children?
The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:
10 Trends for the Future of Anesthesia
Should You Cancel Anesthesia for a Potassium Level of 3.6?
12 Important Things to Know as You Near the End of Your Anesthesia Training
Should You Cancel Surgery For a Blood Pressure = 178/108?
Advice For Passing the Anesthesia Oral Board Exams
What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM.

FREE SOLO

THE ANESTHESIA CONSULTANT Leave a comment
THE ANESTHESIA CONSULTANT
THE ANESTHESIA CONSULTANT
Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com
THE ANESTHESIA CONSULTANT
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Every anesthesia provider must learn to free-solo anesthesia early in his or her career. The 2018 movie Free Solo showcases Alex Honnold as he became the first person to free solo climb the 3000-feet high El Capitan wall of granite in Yosemite National Park without ropes or safety gear. This has been called the greatest feat in rock climbing history, and the movie is nominated for a 2019 Academy Award in the Feature Documentary category.

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FREE SOLO movie poster 2018

Believe it or not, but Free Solo could have been an anesthesiologist’s movie. How can that be? “Free-soloing” describes the most anxiety–producing event in every anesthesiologist’s life: the transition from anesthesia training when your faculty member is backing up your every move and every mistake, to the real world of anesthesia when you have to do scary cases alone without assistance.

During the dayshift, working alone is seldom an issue for any anesthesiologist. A typical hospital will have dozens of other anesthesia providers working in the same building. Within seconds or minutes, any anesthesiologist can be assisted or bailed out by a colleague.

Unlike Alex Honnold, the anesthesiologist is not putting their own life at risk—rather it is their patient who is at risk. The degree of risk is variable. For healthy patients undergoing elective surgery the anesthetic risks are minimal, and are similar to the risks of driving on a freeway in an automobile. For emergency surgeries, cardiac surgeries, chest surgeries, brain surgeries, or for anesthetics on patients with significant heart, lung, blood pressure, or airway problems, the risks of anesthesia are higher. The patient is totally dependent on their anesthesiologist to return them to consciousness safely.

Commercial aviation is sometimes compared to anesthesia practice. When commercial pilots take off in airliners, their passengers are totally dependent on the pilot to return them to the ground safely. But in commercial aviation there is one important difference: by law there must be a second pilot in the cockpit.

In anesthesia there is no guaranteed second anesthesiologist. There are multiple different models of anesthesia care. In an anesthesia care team, a physician anesthesiologist supervises up to four operating rooms and each operating room is staffed with a certified registered nurse anesthetist (CRNA). In a university hospital, a faculty member may supervise two operating rooms each with a resident anesthesiologist-in-training in attendance. In many hospital operating rooms, a solitary physician anesthesiologist attends to his or her patient alone. In seventeen “opt-out” states in America a solitary CRNA can attend to a patient without any physician anesthesiologist backup. Working alone may be less safe. A 2019 study from Europe reported an outcome advantage for anesthesiologist working in teams: The study showed that anesthesia given by teams of anesthesiologists and anesthesia nurses was associated with decreased 30-day postoperative mortality and a shorter length of stay when compared with solo anesthesiologists. There was no evidence for the specific cause of the decreased mortality.

Because of manpower necessities, there will never be a law mandating a second anesthesiologist for every surgery as there is in commercial aviation. There will always be emergencies at 2 a.m. or on weekend afternoons when all other anesthesiologists are elsewhere. As well, there are tens of thousands of freestanding surgery centers and office operating rooms where only one anesthesia professional is present.

Is there any data in the medical literature documenting that inexperienced anesthesia professionals have a greater incidence of adverse outcomes? Per Pubmed, there is no such publication. But there is no publication that denies the truth of this correlation. There is a paucity of data on the topic. The issue has not been rigorously studied in a scientific basis.

I review malpractice legal cases, and I can attest that inexperienced anesthesia personnel (who are less than board-certified physician anesthesiologists) are involved in many cases. I believe recent graduates are at particular risk when they work alone. In most cases with severe complications, the anesthesia professional (an MD or a CRNA) was managing the anesthetic alone until it was too late to save the patient.

During physician anesthesia training, a faculty member teaches, supervises, advises, and bails out each resident should there be a mishap. Following their three years of residency, a graduate is free to take a job as an attending anesthesiologist in any hospital system, multi-specialty clinic, or anesthesia group who will hire him or her. This is when the free-soloing begins.

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Let me cite some examples of anesthesia free-soloing:

  1. The new graduate is on duty at 2 a.m., and a three-hundred-pound man arrives at the emergency room with the abdominal emergency of a dying, obstructed intestine. The surgeon decides the case is an emergency and cannot wait until morning. The typical anesthetic for this surgery is a rapid-sequence induction of intravenous general anesthesia, followed by the placement of a hollow breathing tube through the mouth into the patient’s windpipe. This sounds easy enough, except when it isn’t. Morbidly obese patients can be very difficult to intubate, and without a properly placed breathing tube these patients can be difficult to keep oxygenated. Five minutes without oxygen causes irreversible brain death. Sound scary? It is.
  2. The new graduate is on duty at 3 p.m. at a community hospital. A two-year-old girl arrives at the emergency room gasping for breath, crowing with each inspiration, febrile, drooling, and barely conscious. Both the emergency room physician and the anesthesiologist quickly make the diagnosis of acute epiglottitis, a rare bacterial infection which causes the epiglottis (the flap which covers the windpipe when you swallow) to become inflamed and swollen. This causes a severe obstruction during each inhaled breath. The patient needs a breathing tube within minutes, before the swollen epiglottis cuts off all passage for air inflow into the lungs. I had this very case during my first year in private practice. I’d read about the proper management, but I’d never seen acute epiglottitis myself. The appropriate treatment is to bring the patient to the operating room urgently, and to staff an experienced head and neck surgeon at the bedside. The anesthesiologist’s job is to induce sleep with an inhaled anesthetic (sevoflurane) via a mask, while carefully supporting the airway and facilitating the passage of oxygen and anesthesia gas in and out of the lungs until the patient falls asleep. Once the patient is asleep, a physician or nurse must place an IV catheter in the patient’s arm, and then the anesthesiologist must insert a lighted scope into the patient’s mouth, locate the swollen epiglottis and the opening to the windpipe below it, and insert a tiny hollow plastic breathing tube into the windpipe. If anything goes wrong and the breathing tube cannot be inserted before the child turns blue, the surgeon must immediately slice into the child’s neck and insert a breathing tube through the skin. Once again, five minutes without oxygen causes irreversible brain damage. Sound scary? It is.
  3. The new graduate is on duty alone at a dental office, anesthetizing a 17-year-old male for wisdom teeth removal. After the induction of general anesthesia but before the beginning of surgery, the anesthesiologist administers a requested dose of intravenous antibiotic. Minutes later, the patient’s blood pressure drops from 120/80 to 60/30, the heart rate climbs from 80 to 160 beats per minute, and the normal lung sounds convert to tight wheezes. Hopefully the anesthesiologist will make the correct diagnosis of an anaphylactic allergic reaction—most likely due to the antibiotic. The effective treatment requires perfect management of the patient’s airway, breathing, and circulation. The specific treatment for anaphylaxis requires intravenous injection of epinephrine (adrenaline). A misdiagnosis leading to the omission of epinephrine can be fatal. If the blood pressure remains low and the lungs continue to deteriorate, there will be a lack of oxygen delivery to the brain. Once again, five minutes without oxygen causes irreversible brain damage. Sound scary? It is.

What can be done to make free-soloing safer for patients? In my opinion, the best safety ropes are these:

  1. Most hospitals have an emergency room physician on duty at all hours. These MDs are multi-talented and have the acute care skills necessary to assist an anesthesiologist in an emergency. Rather than waiting until a patient has a cardiac arrest or until an airway is lost and the patient’s brain is losing oxygen, an anesthesia professional can consult the ER doctor in advance, e.g. requesting them to assist with a difficult induction of anesthesia on a morbidly obese adult or with a child with a difficult airway.
  2. Even if no experienced anesthesiologist is present in the hospital, there is always an experienced physician anesthesiologist colleague available on the other end of a phone call. Young or inexperienced anesthesia professionals can telephone senior anesthesiologists prior to the anesthetic, whenever a situation arises in which they are doubtful, insecure, or uncomfortable. It’s difficult to admit a lack of confidence, but it’s better to do this than to review a terrible complication with the senior anesthesiologist the next day, like two firefighters gazing over the burned basement remains of a previously preserved house.
  3. Most American anesthesia training programs are now utilizing simulation training facilities to prepare residents for severe acute care scenarios. A simulator lab has a surrogate patient and a full battery of vital sign monitors under the control of a teacher. The teacher can dial in a variety of emergencies and observe the pupil’s response to the emergencies. Feedback is given afterward regarding observed errors and any needed improvements in management. If a young physician anesthesiologist has faced emergencies in the simulator, we believe the anesthesiologist will be better prepared to free-solo following their training.
  4. The Stanford Anesthesiology department authored the Stanford Cognitive Aid Emergency Manual, a booklet of itemized recipes and checklists for all common dire emergencies one might see in an operating room. A PDF of this booklet is available for free of charge download here. Using the Stanford Cognitive Aid Emergency Manual in the operating room will help prevent medical errors, even by inexperienced anesthesia professionals.
  5. Whenever possible, solo anesthesiologists should have already passed the American Board of Anesthesiologists written and oral examinations, and therefore be board-certified. It’s a fact that one can practice anesthesiology in the United States without being board certified, but the ABA oral examination forces graduates to answer difficult questions in the pressure cooker of an oral exam room. Board-certified anesthesiologists will be better prepared for the pressure cooker of an operating room emergency as well.

If you’re a patient, should you worry about your anesthetist free-soloing during your surgery?

Let me reassure you. If you’re having an elective surgery in a hospital in the daytime, there are usually multiple backup anesthesia providers to assist with any problems. But for emergencies in the middle of the night, on weekends, or at freestanding surgical facilities with only one anesthesiologist present, your anesthesia care and outcome will be solely dependent on the skills, training, and experience of the solitary individual who is attending to you.

I’ve stood at the bottom of El Capitan in Yosemite National Park and looked upward at the vertical granite face with awe. I could never climb El Capitan, with or without ropes. I respect what Alex Honnold did at the highest level. He is brave beyond measure and he was willing to put his life on the line. Anesthesiologists, particularly junior anesthesiologists, must free-solo as well. No Hollywood cameras will be rolling, but the adrenaline will be pumping through their veins just as if they themselves were climbing El Capitan.

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The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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AN ANESTHESIOLOGIST’S SALARY

THE ANESTHESIA CONSULTANT 2 Comments
THE ANESTHESIA CONSULTANT
THE ANESTHESIA CONSULTANT
Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com
THE ANESTHESIA CONSULTANT
Latest posts by THE ANESTHESIA CONSULTANT (see all)

How much money does an anesthesiologist earn? What is a physician anesthesiologist’s salary in today’s marketplace?

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Let me begin by offering two anecdotes:

  • I was an invited visiting anesthesia professor at a major university this year, and following one of my lectures an anesthesiology resident approached me for a discussion. During our conversation he revealed that his student loan debt was $300,000. In 2014 the published average student loan debt for a physician was $183,000. I believe a higher estimate is not unusual, particularly if the student doctor attended private medical school and/or college.
  • I recently received an email from a medical student who was considering anesthesia as a career specialty, but his concern was: is the bottom about to fall out for anesthesiologists’ salaries? Should he perhaps avoid a career in anesthesiology?

Each anecdote concerns the issue of how much anesthesiologists earn, and what will that number be in the future?

The good news for the future of anesthesia careers is that the number of surgeries in the United States is expected at increase as the Baby Boomers age. The demand for anesthesia services will grow. Who will provide these services, and what will they be paid?

How much money do anesthesiologists currently make?

It depends.

If you do a Google search on this question, most of the published answers vary from $275,000 to $360,000 per year.

This sounds like a lot of money, but recall that to reach that salary, an anesthesiologist must finish 4 years of medical school and a 4-year anesthesia residency. At a minimum these young anesthesiologists are 30 years old. The deferred gratification is significant. Had they gone to work after college at age 22 and been promoted in a business job for 8 years, that individual might own a home, be saving for their children’s college educations, and would not have the debt from 4 years of medical school.

Let’s assume an individual does persevere and finish their anesthesia residency at age 30, and is now seeking an anesthesia job with that aforementioned average salary of $275,000 to $360,000 per year.

The first question: is that advertised salary a number prior to deductions for the big three of pension plan, health insurance, and malpractice insurance? If an anesthesiologist earns $300,000 per year, but must subtract these three expenses (let’s estimate pension plan at $45,000, health insurance at $24,000, and malpractice insurance at $20,000) then the income drops to $300,000 minus $89,000 = $211,000 per year, or $17,583 per month before taxes. Subtract again for student loan payments, and the income level continues to decrease. So a critical first question to ask is if the big three benefits are/are not part of the promised salary.

What specific factors determine how high the anesthesiologist’s salary will be? An operating room anesthesia practice is somewhat akin to being a taxi cab driver. You earn income for each ride/anesthetic, and your income depends on how many rides/anesthetics and how long they last. More complex anesthetics such as cardiac cases pay more, but the largest determiner is the duration of time one spends giving the anesthesia care. If you work in a physician anesthesiology practice where an MD stays with each surgical patient 100% of the time, then the only way to increase income is to do more cases or more hours. If you work in a practice which utilizes an anesthesia care team, where one physician anesthesiologist may supervise, for example, 4 Certified Registered Nurse Anesthetists (CRNAs), then a physician’s income is increased because he or she is billing for and supervising care for multiple concurrent surgeries.

Different payers pay different sums per unit time. The top payers are insured patients of less than Medicare age (<65 years old). Among the lowest payers are uninsured patients (who often pay zero), Medicaid and Medicare patients, and Worker’s Compensation patients. Medicare patients routinely pay only 13-20 cents on the billed dollar, and Medicaid pays even lower, so a practice heavy with Medicare and Medicaid patients will compensate their anesthesiologists poorly. Insurance companies (i.e. Blue Cross, Blue Shield, Aetna, United Healthcare) pay whatever rate they have contracted with that anesthesia group. If a particular insurance company pays a low rate, an anesthesia group may refuse to sign a contract with that insurance company. This leaves the anesthesiologist out-of-network with that company, which can mean a higher payment or co-payment for the patient as a result of the insurance company’s refusal to negotiate a fair reimbursement.

Just as taxi cab drivers are being supplanted by Uber and Lyft, cheaper models of anesthesia care are popping up, and the penetration of these models into the future marketplace is unknown. One model is having a CRNA do the anesthetic independently without any physician anesthesiologist present. This is currently legal in 27 states (see map). At the current time, in my home state of California, independent CRNA practice is legal, but the penetration of this model in the marketplace is very minimal. The Veterans Affairs hospitals are currently pondering a move to allow CRNAs to practice independently without any physician anesthesiologist present. You can expect to see a higher penetration of the anesthesia care team, where one physician anesthesiologist may supervise, for example, 4 CRNAs, and a decrease in practices where an MD anesthesiologist stays with each patient 100% of the time.

To be blunt, my impression is that the future marketplace is unlikely to pay for a physician anesthesiologist to do solo anesthesia care for each and every surgical patient.

In the current marketplace a young graduate anesthesiologist may enter one of several different models of anesthesia practices. Each has a different level of salary expectation. The various models are listed below, in roughly a higher-income-per-anesthesiologist to lower-income-per-anesthesiologist order:

  1. A single-specialty anesthesia group that shares income fairly. This group may be as small as 5 or as large as hundreds of physician anesthesiologists, with or without additional CRNAs. Such a group usually has an exclusive contract with a hospital or hospitals to provide all anesthesia services, which can include trauma, obstetrics, and 24-hour emergency room coverage. A very large single-specialty anesthesia group may contract with many hospitals in a geographic area. In a single-specialty model, that single-specialty group receives all the anesthesia billings, and the income is divided, usually in some form of “eat-what-you-provided” formula. Those MDs who worked the most receive a proportional increase in their income. A new MD may have a one-year try-out before they become a partner, after which they are entitled to an equal income per unit time. This model where anesthesiologists are partners, is typically more lucrative than models where the anesthesiologists are employed by another entity. A survey by Medscape on anesthesiologists’ salaries in 2016 showed that male self-employed anesthesiologists (model #1) earned an average income of $413,000, while male anesthesiologist employees (see models #2 – #8 below) earned an average income of $336,000.
  2. A single-specialty anesthesia group in which a chairman (or a small oligopoly of MDs) collect the money, and then employ and grant a salary to everyone below them in the company. New hires are paid less, often with no potential to increase their income. This type of system preys on junior anesthesiologists.
  3. A multispecialty medical group. A multispecialty medical group has a bevy of primary care physicians who refer internally to their specialist surgeons, who then utilize their internal group of anesthesiologists. This is a secure job for anesthesiologists because the stream of cases is guaranteed by the physicians within their multispecialty group. A disadvantage is that incomes from lower paying specialties (primary care MDs) and higher paying specialties (i.e. cardiologists, surgeons, and anesthesiologists) are pooled. The lower paying specialists usually have their salaries raised, and the anesthesiologists will be subsidizing them.
  4. An HMO. In California the Health Maintenance Organization (HMO) Kaiser Permanente has a large share of the marketplace. The entity known as the Permanente Medical Group is the multispecialty integrated medical group which works at the Kaiser hospitals and clinics. The reimbursement model will be similar to that described in #3 above.
  5. University anesthesia groups. A university employs MDs as a multispecialty medical group, and the model is similar to #3 above. A difference is that university groups have various taxes and fees on their income that go to the betterment and growth of the medical school and the university hospital system. In addition, some university hospitals provide care to indigent populations that may have higher percentage of poor payers such as Medicaid or uninsured patients.
  6. National anesthesia companies. In this model, a national company obtains the anesthesia contract for a hospital or multiple facilities, and then that national company hires and employs anesthesiologists. The company bills for the anesthesia services provided, pays their employee anesthesiologists whatever sum they’ve agreed to pay them, and the difference between the received monies and the owed salaries is profit that goes to stockholders of the national company. This model is problematic for our specialty, because a percentage of the anesthesia fees goes to stockholders who had zero to do with performing the professional service.
  7. Veteran’s Affairs (VA) hospital anesthesia groups. At the present time, VA hospitals are staffed by anesthesiologists who are employees of the VA system. As mentioned above, there are politicians pushing for the VA to allow CRNAs to practice independently, unsupervised by physician anesthesiologists. The American Society of Anesthesiologists is opposed to this change, believing that our veterans deserve physician anesthesiologists.
  8. Locum tenens assignments. These are part-time, week-long, or month-long anesthesia duties, paid for at a daily rate. A typical fee for a full day’s work may be a pre-tax payment of $1200/day (not including the big three of pension, health or malpractice insurance).

As stated above, the good news for the future of anesthesia careers is that the number of surgeries in the United States is expected at increase as the Baby Boomers age. The demand for anesthesia services will grow. The unknown fiscal factors for the future of our specialty are:

  1. What will insurers/Medicare/Medicaid/the Affordable Care Act pay for these anesthesia services? Will a single payer government health plan ever arrive, and if it does what will anesthesiologists be paid?
  2. Who will be giving these services? Physician anesthesiologists, anesthesia care teams involving physician anesthesiologists plus CRNAs, anesthesia care teams involving physician anesthesiologists plus Anesthesia Assistants, or independent CRNAs?
  3. The American Society of Anesthesiologists is attempting to rebrand the practice of anesthesiology with the concept of the Perioperative Surgical Home (PSH), in which physician anesthesiologists are responsible for all aspects of preoperative, intraoperative, and postoperative medical care for patients around the time of surgery. This expanded role includes preoperative clinics and postoperative pain control and medical management. To what degree can/will the PSH change the job market for graduating anesthesiologists?

In any case, as I wrote on the Home Page of theanesthesiaconsultant.com website, “the profession of medicine offers a lifetime of fascination, and no specialty is more fascinating than anesthesiology.” If a college student or a medical student is truly interested in a career in anesthesia, I remain encouraging to them, regardless of these uncertainties regarding the future.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

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Check out . . . THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

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LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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TEN REASONS NURSE ANESTHETISTS (CRNAs) WILL BE A MAJOR FACTOR IN ANESTHESIA CARE IN THE 21ST CENTURY

THE ANESTHESIA CONSULTANT 5 Comments
THE ANESTHESIA CONSULTANT
THE ANESTHESIA CONSULTANT
Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com
THE ANESTHESIA CONSULTANT
Latest posts by THE ANESTHESIA CONSULTANT (see all)

 

My debut novel, The Doctor and Mr. Dylan features a nurse anesthetist in the starring role of Mr. Dylan. Nurse anesthetists have provided anesthesia care in the United States for nearly 150 years, and CRNs will be a major factor in the future.

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In the beginning, anesthesia care for surgical patients was often provided by trained nurses under the supervision of surgeons, until the establishment of anesthesiology as a medical specialty in the U.S. in the 20th century.

Here are 10 reasons why certified registered nurse anesthetists (CRNAs) will be a major factor in anesthesia care in the 21st century:

1. Rural America is dependent on CRNAs to staff surgery in small towns underserved by MD anesthesiologists. CRNAs are involved in providing anesthesia services to about one-quarter of the American population that resides in rural and frontier areas of this country. Despite a significant rise in the number of anesthesiologists in recent years, there is no evidence that they are attracted to practice in rural areas.
2. Obamacare will increase the demand for mid-level healthcare providers, e.g. nurse practitioners, physician assistants, and nurse anesthetists. These mid-level providers are perceived as a cheaper alternative to MD health care.
3. Seventeen states have opted out of the requirement for physician supervision of CRNA anesthetics. These states are Iowa, Nebraska, Idaho, Minnesota, New Hampshire, New Mexico, Kansas, North Dakota, Washington, Alaska, Oregon, Montana, South Dakota, Wisconsin, California, Colorado, and Kentucky. In these states, it’s legal for a CRNA to give an anesthetic without a supervising anesthesiologist or surgeon.
4. For cost-saving reasons, hospital administrators will consider the lower hourly rate charged by CRNAs to be a saving over MD anesthesia care rendered by anesthesiologists alone.
5. Future trends such as the American Society of Anesthesiologists’ Perioperative Surgical Home or bundled payments to Accountable Care Organizations will seek out the cheapest way to manage anesthetic populations. A likely economic model for a healthy patient population is the anesthesia care team, e.g. a 4:1 ratio of four CRNAs supervised by one MD anesthesiologist. This model can be used to staff four simultaneous surgeries on four healthy patients having simple surgical procedures. More complex procedures such as open-heart surgery, brain surgery, major vascular surgery, or emergency surgery will be best served by MD anesthesia care. Extremes of age (e.g. neonates or very old patients) and patients with significant medical comorbidities will be best served by MD anesthesia care.
6. Certain regions of the United States, particularly the South and the Midwest, are already entrenched with anesthesia care team models of 3:1 or 4:1 CRNA:MD staffing because of anesthesiologist preference. An MD anesthesiologist’s income can be augmented by supervising three or four operating rooms with multiple CRNAs simultaneously. These physicians will have little desire to rid themselves of nurse anesthetists and to personally do only one case at a time by themselves.
7. The American Association of Nurse Anesthetists (AANA) presents a strong, well-funded lobby which promotes the continuing and increasing role of CRNAs in medical care in the United States.
8. The educational cost for a registered nurse to become a CRNA is significantly less than the cost of training a board-certified MD anesthesiologist. The median cost of a public CRNA program is $40,195 and the median cost of a private program is $60,941, with an overall median of $51,720.
9. A registered nurse can significantly increase their income by becoming a CRNA. A registered nurse with one year of intensive care unit or post-anesthesia care unit experience can become a CRNA with 2-3 years of CRNA schooling. The average yearly salary of a CRNA in America in 2011 was $156,642.
10. The increasing starring role of CRNAs in American fiction ☺. (See The Doctor and Mr. Dylan, below)

After perusing this list one might ask, are CRNAs and anesthesiologists equals?
No, they are not. Anesthesiologists are doctors, and their training of four years of medical school followed by a minimum of four years of anesthesia residency makes them specialists in all aspects of surgical medicine.

The American Society of Anesthesiologists’ STATEMENT ON THE ANESTHESIA CARE TEAM states “Anesthesiology is the practice of medicine including, but not limited to, preoperative patient evaluation, anesthetic planning, intraoperative and postoperative care and the management of systems and personnel that support these activities. In addition, anesthesiology includes perioperative consultation, the management of coexisting disease, the prevention and management of untoward perioperative patient conditions, the treatment of acute and chronic pain, and the practice of critical care medicine. This care is personally provided by or directed by the anesthesiologist.” (Approved by the ASA House of Delegates on October 26, 1982, and last amended on October 16, 2013)

Doctor J H Silber’s landmark study from the University of Pennsylvania documented that both 30-day mortality and failure-to-rescue rates were lower when anesthesia care was supervised by anesthesiologists, as opposed to anesthesia care by unsupervised nurse anesthetists. This study has been widely discussed. The CRNA community dismissed the conclusions, citing that the Silber study was a retrospective study. In a Letter to the Editor published in Anesthesiology, Dr. Bruce Kleinman wrote regarding the Silber data, “this study could not and does not address the key issue: can CRNAs practice independently?”

I’m not a fan of CRNAs working alone without physician supervision. In both my expert witness practice and in the expert witness practice of my anesthesia colleagues, we find multiple adverse outcomes related to acute anesthetic care carried out by non-anesthesiologists.

CRNAs will play a significant role in American healthcare in the future. That significant role will be best played with an MD anesthesiologist at their right hand.

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

 

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

41wlRoWITkL

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

DSC04882_edited

 

 

OBAMACARE AND ANESTHESIA

THE ANESTHESIA CONSULTANT 1 Comment
THE ANESTHESIA CONSULTANT
THE ANESTHESIA CONSULTANT
Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com
THE ANESTHESIA CONSULTANT
Latest posts by THE ANESTHESIA CONSULTANT (see all)

Key questions in our specialty in 2014 related to Obamacare and anesthesia. This article was originally published in 2014, when Barack Obama was the President of the United States. A key question in our specialty at that time was “How will ObamaCare affect anesthesiology?” The following essay represents my thoughts as of 2014, prior to the Trump presidency.

I don’t have a crystal ball, but based on what I’ve read, what I’ve observed, and what I’m hearing from other physicians, these are my predictions on how ObamaCare will change anesthesia practice in the United States:

  1. There will be more patients waiting for surgery. Millions of new patients will have ObamaCare cards and coverage. A flawed premise of ObamaCare is that a system can cover more patients and yet spend less money.
  2. Reimbursement rates will be lower. How many anesthesiologists will sign up for Medicaid or Medicare-equivalent rates to care for patients? Large organizations such as university hospitals, Kaiser, Sutter, and other HMO-types will likely sign up for the best rate they can negotiate. As a result, their physicians will have increased patient numbers and lower reimbursement for their time. The insurance plans that patients purchase will have higher deductibles, and most patients will have to pay more out of pocket for their surgery and anesthesia. This will lead to patients delaying surgery, and shopping around to find the best value for their healthcare dollar.
  3. Less old anesthesiologists. Older anesthesiologists will retire early rather than work for markedly reduced pay.
  4. Less young anesthesiologists. The pipeline of new, young anesthesiologists will slow. Young men and women are unlikely to sign up for 4 years of medical school,  4 – 6 years of residency and fellowship, and an average of $150,000 of student debt if their income incentives are severely cut by ObamaCare.
  5. More certified nurse anesthetists (CRNAs). It seems apparent that ObamaCare is interested in employing cheaper providers of medical services. CRNAs will command lower salaries than anesthesiologists. The premise to be tested is whether CRNAs can provide the same care for less money. Expect to see wider use of anesthesia care teams and of independent CRNA practice. Expect the overall quality of anesthesia care to change as more CRNAs and less M.D.’s are employed.
  6. A two-tiered system. Anesthesiologists who have a choice will not sign up for reduced ObamaCare rates of reimbursement. Surgeons who have a choice will not sign up for reduced ObamaCare reimbursement. Expect a second tier of private pay medical care to exist, where patients will choose non-ObamaCare M.D.’s of their choice, and will pay these physicians whatever the physicians charge. This tier will provide higher service and shorter waiting times before surgery is performed. This tier will likely be populated by some of the finest surgeons–surgeons are unwilling to work for decreased wages. A subset of anesthesiologists will work in this upper tier of medical care, and these anesthesiologists will earn higher wages as a result.
  7. Will the Accountable Care Organization (ACO) model stumble as the Health Maintenance Organization (HMO) model did in the 1990’s? ObamaCare provides for the existence of ACO’s, which are hospital-physician entities designed to provide comprehensive health care to patients in return for bundled payments. In this model the surgeon, the anesthesiologist, and the hospital (i.e. nurses, pharmacy, and the medical device industry) will divide up the bundled surgical payment. In this model it’s essential that an anesthesiologist leader has a strong presence at the negotiating table. A worrisome issue with the ACO model, as it was with the HMO model, is the flow of money. Physicians will no longer be working for their patients, but will be working for the ACO. The  primary incentive will be to be paid by the ACO, rather than to provide the best care possible.
  8. Anesthesia leadership skills will change. The physician leader of each anesthesia group must be a powerful and effective politician and economic strategist. These traits are not taught during anesthesia residency, and these traits have nothing to do with being an outstanding clinician.
  9. What about the Perioperative Surgical Home (PSH)? The American Society of Anesthesiologists is proposing the model of the PSH, in which anesthesiologists will assume leadership roles managing patient care in the preoperative, intraoperative, and postoperative arenas. This is a desirable goal for our specialty. No physician is better equipped than an anesthesiologist to supervise patients safely through the perioperative period with the highest standards of quality and cost-control. The Perioperative Surgical Home is designed to work with the model of the Accountable Care Organization. How these systems of the Perioperative Surgical Home and the Accountable Care Organization will evolve remains to be seen. It will be the role for individual anesthesia physician leaders in each hospital to seize the new opportunities.  Rank and file anesthesiologists will likely follow their leadership.

10. Consolidation of anesthesia groups. Small anesthesia groups will likely merge into bigger groups in an effort dominate a clinical census, and therefore to negotiate higher reimbursement rates. In November, 2013, the 100-physician Medical Anesthesia Consultants Medical Group, Inc, of San Ramon, California was acquired by Sheridan Healthcare Inc, a 2,500-physician services company based in Florida. Per Sheridan’s CEO, John Carlyle, the acquisition “provides a platform that will accelerate our expansion in the California marketplace.” This was the largest merger in Northern California anesthesia history.

11. Requirement of more anesthesia clinical metrics. Government and insurance payors will require more metrics to document that the provided clinical care was excellence. A typical required metric may be a high percentage of patients who received preoperative antibiotics prior to incision, or a low percentage of patients free from postoperative nausea and vomiting. Each anesthesia groups will need to establish computerized data-capturing systems to present this information to payors. The effort to tabulate these metrics will be another incentive for anesthesia groups to merge into larger clinical entities.

In summary:  More patients, more cases, less money, more bureaucracy, less money, more CRNA providers, and less money. These are the challenges ObamaCare presents to anesthesiologists. Stay tuned. Legions of patients with ObamaCare cards will be knocking on hospital doors. The government is expecting enough anesthesiologists to sign up for ObamaCare contracts to make the new system successful. It’s impossible to tell what behaviors ObamaCare will incentivize. Each anesthesiologist has the benefit of 25+ years of education, and each anesthesiologist will make intelligent choices regarding their career and their time.

Bob Dylan once sang, “I ain’t gonna work on Maggie’s Farm no more.”

Time will tell if ObamaCare is Maggie’s Farm for physicians.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

41wlRoWITkL

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

DSC04882_edited

 

 

WILL YOU HAVE AN ANESTHESIOLOGIST FOR YOUR WISDOM TEETH EXTRACTION SURGERY?

THE ANESTHESIA CONSULTANT 20 Comments
THE ANESTHESIA CONSULTANT
THE ANESTHESIA CONSULTANT
Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com
THE ANESTHESIA CONSULTANT
Latest posts by THE ANESTHESIA CONSULTANT (see all)

In the United States, will you have an anesthesiologist for your wisdom teeth extraction surgery? If you are a healthy patient, the answer is: probably not.

In the United States, oral surgeons perform most wisdom teeth extraction surgeries.  This is a very common surgery, with the operation performed on up to five million times in the United States each year. Most patients are healthy teenagers.  Oral surgeons perform wisdom teeth surgeries in their office operating rooms, and most oral surgeons manage the intravenous sedation anesthesia themselves, without the aid of an anesthesiologist.

Oral surgeons are trained in the airway management and general anesthesia skills necessary to accomplish this safely, and a nurse assists the oral surgeon in delivering sedative medications.  Oral surgeons must earn a license to perform general anesthesia in their office. To administer general anesthesia in an office, most oral surgeons complete at least three months of hospital-based anesthesia training. In most states, oral surgeons then undergo an in-office evaluation by a state dental-board-appointed examiner, who observes an actual surgical procedure during which general anesthesia is administered to a patient. It’s the examiner’s job to inspect all monitoring devices and emergency equipment, and to test the doctor and the surgical staff on anesthesia-related emergencies. If the examinee successfully completes the evaluation process, the state dental board issues the doctor a license to perform general anesthesia.  Note that even though the oral surgeon has a license to direct anesthesia, the sedating drugs he or she orders are often administered by a nurse who has no license or training in anesthesia.

In an oral surgeon’s office, general anesthesia for wisdom teeth extraction typically includes intravenous sedation with several drugs:  a benzodiazepine such as midazolam, a narcotic such as fentanyl or Demerol, and a hypnotic drug such as propofol, ketamine, and/or methohexital.  Prior to administering these powerful drugs, the oral surgeon must be certain that he or she can manage the Airway and Breathing of the patient. After the patient is asleep, the oral surgeon injects a local anesthetic such as lidocaine to block the superior and inferior alveolar nerves.  These local anesthetic injections render the mouth numb, so the surgeon can operate without inflicting pain.  Typically, no breathing tube is used and no potent anesthetic vapor such as sevoflurane is used.  The oral surgeon may supplement intravenous sedation with inhaled nitrous oxide.

The oral surgeon has all emergency airway equipment, breathing tubes, and emergency drugs available. The safety record for oral surgeons using these methods seems excellent.  My review of the National Institutes of Health website PubMed reveals very few instances of death related to wisdom teeth extraction.  Recent reports include one patient who died in Germany due to a heart attack after his surgery (Kunkel M, J Oral Maxillofac Surg. 2007 Sep;65(9):1700-6.  Severe third molar complications including death-lessons from 100 cases requiring hospitalization).  A second patient died in Japan because of a major bleed in his throat occluding trachea, one day after his surgery (Kawashima W, Forensic Sci Int. 2013 May 10;228(1-3):e47-9. doi: 10.1016/j.forsciint.2013.02.019. Epub 2013 Mar 26. Asphyxial death related to postextraction hematoma in an elderly man).

Most oral surgeons do not publish their mishaps or complications, so the medical literature is not the place to search for data on oral surgery deaths. Deaths that occur during or after wisdom teeth extraction are sometimes reported in the lay press.  In April 2013, a 24-year-old healthy man began coughing during his wisdom teeth extraction in Southern California, and went into cardiac arrest.  He was transferred to a hospital, where he died several days later.

In 2011, a Baltimore-area teen died during wisdom teeth extraction. The family’s malpractice claim was settled out of court in 2013.

Every general anesthetic carries a small risk, such as these two reported cases of death following wisdom teeth extractions.  All acute medical care involves attending to the A – B – C ‘s of Airway, Breathing, and Circulation.  During surgery for wisdom teeth extraction, the oral surgeon is operating in the patient’s mouth. Surgery in the mouth increases the chances that the operation will interfere with the patient’s Airway or Breathing.  The surgeon’s fingers, surgical instruments, retractors, and gauze pads crowd into the airway, and may influence breathing.  If the patient’s breathing becomes obstructed, altering the position of the jaw, the tongue, or the neck is more challenging than when surgery does not involve the airway.

I’ve attended to hundreds of patients for dental surgeries.  For dental surgery in a hospital setting, anesthesiologists commonly insert a breathing tube into the trachea after the induction of general anesthesia.  A properly positioned tracheal tube can assure the Airway and Breathing for the duration of the surgery.  Because an anesthesiologist is not involved with performing the surgery, his or her attention can be 100% focused on the patient’s vital signs and medical condition.  When anesthesiologists are called on to perform general anesthesia for wisdom teeth extraction in a surgeon’s office, we typically use a different anesthetic technique.  Usually there is no anesthesia machine to deliver potent inhaled anesthetics, therefore intravenous sedation is the technique of choice.  Usually no airway tube is inserted.  When general anesthesia is induced in an office setting, the patient must have an adequate airway, i.e. and American Society of Anesthesiologists Class I or II airway. A typical technique is a combination of intravenous midazolam, fentanyl, propofol, and/or ketamine.  Oxygen is administered via the patient’s nostrils throughout the surgery. The adequacy of breathing is continuously monitored by both pulse oximetry and end-tidal carbon dioxide monitoring.  The current American Society of Anesthesiologist Standards for Basic Anesthetic Monitoring (July 1, 2011) state that “Every patient receiving general anesthesia shall have the adequacy of ventilation continually evaluated. … Continual monitoring for the presence of expired carbon dioxide shall be performed unless invalidated by the nature of the patient, procedure or equipment.”

The motto of the American Society of Anesthesiologists is “Vigilance.”  If the patient’s oxygen saturation and/or end-tidal carbon dioxide numbers begin to decline, an anesthesiologist will act immediately to improve the A – B – C ‘s of Airway, Breathing, and Circulation.

Let’s return to our opening question: Will you have an anesthesiologist for your wisdom teeth extraction surgery?  If you are a healthy patient, I cannot show you any data that an anesthesiologist provides safer care for wisdom teeth surgery than if an oral surgeon performs the anesthesia. The majority of wisdom teeth extractions in the United States are performed on healthy patients without an anesthesiologist, and reported complications are rare.  If you want an anesthesiologist, you need to make this clear to your oral surgeon, and ask him to make the necessary arrangements.  If you do choose to enlist a board-certified anesthesiologist for your wisdom teeth extractions, know that your anesthesia professional has completed a three or four year training program in his field, and is expert in all types of anesthesia emergencies.  As a downside, you will be responsible for an extra bill for the professional fee of this anesthesiologist.

Whether an anesthesiologist or an oral surgeon attends to your anesthesia, the objectives are the same:  Each will monitor the A – B – C ‘s of your Airway, Breathing, and Circulation to keep you oxygenated and ventilated, so you can wake up and leave that dental office an hour or so after your wisdom teeth extraction surgery has concluded.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

41wlRoWITkL

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

DSC04882_edited

 

CAN YOU CHOOSE YOUR ANESTHESIOLOGIST?

THE ANESTHESIA CONSULTANT Leave a comment
THE ANESTHESIA CONSULTANT
THE ANESTHESIA CONSULTANT
Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com
THE ANESTHESIA CONSULTANT
Latest posts by THE ANESTHESIA CONSULTANT (see all)

You choose the car you drive, the apartment you rent, the smart phone in your pocket, and the flavor of ice cream among 31 flavors at Baskin-Robbins.  Most of you  choose your family physician, your dermatologist, and your surgeon.  But can you choose your anesthesiologist?

 

It depends.

To answer the question, let’s look at how anesthesia providers are assigned for each day of surgery.

Who makes the decision as to which anesthesia provider is assigned to your case? The anesthesia service at every hospital or healthcare system will have a scheduler.  This scheduler is an individual (usually an anesthesiologist) who surveys the list of the surgical cases one day ahead of time.  There will be multiple operating rooms and multiple cases in each operating room. Each operating room is usually scheduled for six to ten hours of surgical cases.  The workload could vary from one ten-hour case to eight shorter cases.  The total number of operating rooms will vary from hospital to hospital.  Typically each room is specialty-specific, that is, all the cases in each room are the same type of surgery.  The scheduler will an assign appropriate anesthesia provider to each room, depending on the skills of the anesthesia provider and the type of surgery in that room.

There are multiple surgical specialties and multiple types of anesthetics.  An important priority is to schedule an anesthesia provider who is skilled and comfortable with the type of surgery scheduled.  An open-heart surgery will require a cardiac anesthesiologist.  A neonate (newborn) will require a pediatric anesthesiologist.  Most surgeries, e.g., orthopedic, gynecologic, plastic surgery, ear-nose-and-throat, abdominal, urologic, obstetric, and pediatric cases over age one, are bread-and-butter anesthetics that can be handled by any well-trained provider.

Each day certain anesthesiologists are “on-call.”  When an anesthesiologist is on-call, he or she is the person called for emergency add-on surgeries that day and night.  The on-call anesthesiologist is expected to work the longest day of cases, and the scheduler will usually assign that M.D. to an operating room with a long list of cases.  If you have emergency surgery at 2 a.m., you will likely be cared for by the on-call anesthesiologist.  A busy anesthesia service may have a first-call, a second-call, and a third-call anesthesiologist, a rank order that defines which anesthesia provider will do emergency cases if two or three come in simultaneously.  A busy anesthesia service will have on-call physicians in multiple specialties, i.e., there will be separate on-call anesthesiologists for cardiac cases, trauma cases, transplant cases, and obstetric cases.

Different hospitals have different models of anesthesia services.  In parts of the United States, especially the Midwest, the South, and the Southeast, the anesthesia care team is a common model.  An anesthesia care team consists of both certified registered nurse anesthetists (CRNA’s) and M.D. anesthesiologists.  For complex cases such as cardiac cases or brain surgeries, an M.D. anesthesiologist may be assigned as the solitary anesthesia provider.  For simple cases such as knee arthroscopies or breast biopsies, the primary anesthesia provider in each operating room will be a CRNA, with one M.D. anesthesiologist serving as the back-up consultant for up to four rooms managed by CRNA’s.

In certain states, the state governor has opted out of the requirement that an M.D. anesthesiologist must supervise all CRNA-provided anesthesia care.  In these states, a CRNA may legally provide anesthesia care without a physician supervising them.  Currently, the seventeen states that have opted out of physician supervision of CRNA’s include Alaska, California,  Colorado, Iowa, Idaho, Kansas, Kentucky, Minnesota, Montana, Nebraska, New Hampshire, New Mexico, North Dakota, Oregon, South Dakota, Washington, and Wisconsin.  In some hospitals in these states, your anesthesia provider may be an unsupervised nurse anesthetist, not a doctor at all.

Some hospitals have only M.D. anesthesiologists who personally do all the cases.

Academic hospitals, or university hospitals, have residents-in-training who administer most of the anesthetic care.  In academic hospitals, faculty members supervise anesthesia residents in a ratio of one faculty to one resident or one faculty to two residents.

Can a surgeon request a specific anesthesia provider?  Yes.  At times, a surgeon may have certain anesthesia providers that he or she requests and uses on a regular basis.  It’s far easier for a surgeon to request a specific anesthesia provider than it is for you to do so.

The assignment of your anesthesia provider is usually made by the scheduler on the afternoon prior to surgery, and you the patient will have little or no say in the matter. If you are like most patients, you have no idea who is an excellent anesthesia provider and who is less skilled. You won’t find much written about anesthesiologists on Yelp, Healthgrades, or other consumer social-media websites.  Most patients don’t even remember the name of their anesthesia provider unless something went drastically wrong.  Such is the nature of our specialty.  Your anesthesia provider will spend a mere ten minutes with you while you’re awake, and during those ten minutes your mind will be reeling with worries about surgical outcomes and risks of anesthesia.  The anesthesia provider’s name is not a high priority.  After the surgery is over, anesthesiologists are a distant memory.

What if your next-door neighbor is an anesthesiologist whom you respect?  What if you are scheduled for surgery at his hospital or surgery center, and you want him to take care of you?  Can this be arranged?  Most likely, it can.  The best plan for requesting a specific anesthesiologist is to have the anesthesiologist work the system from the inside, several days prior to your surgery date.  He will talk to the scheduler and make sure that he is assigned into the operating room list that includes your surgery.  You’ll be happy and reassured to see him on the day of surgery, and he’ll likely be happy to take care of you.  Anesthesiologists love to be requested by patients.  It makes us feel special.  Doctors aspire to be outstanding clinicians, and a request from a specific patient validates that we are unique.

As you can see, the decision of who is assigned to be the anesthesia provider for your surgery is a multifaceted process. Your best strategy for requesting a specific anesthesiologist is to (1) contact the anesthesiologist yourself and ask that he or she contact anesthesia scheduling and make sure that he or she is scheduled to do your case, or (2) contact your surgeon and ask your surgeon if they can arrange to have the specific anesthesia provider that you request.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

*
*
*
*

Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

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

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

THE ANESTHESIA CONSULTANT Leave a comment
THE ANESTHESIA CONSULTANT
THE ANESTHESIA CONSULTANT
Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com
THE ANESTHESIA CONSULTANT
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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 physician anesthesiologists.

 

 

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

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