Who is responsible for your safety before, during, and after your surgery? Will it be a nurse or will it be a physician? This is an important question. Perioperative mortality is the third leading cause of death in the United States after heart disease and cancer. This statement appeared in the July 2021 issue of Anesthesiology, our specialty’s leading journal. We’re all aware of the threats from heart disease or cancer, but most people know next to nothing about “perioperative mortality.” What is perioperative mortality?
The word “perioperative” means “around the time of surgery.” It’s officially defined as the 30-day time period following surgery. “Mortality” means a patient death. Any patient who dies within 30 days of their anesthetic qualifies as a perioperative mortality. Very few patients die in the operating room, but significant numbers die in the weeks that follow.
Why do patients die? A 2013 study in Anesthesiology states, “Despite the fact that a surgical procedure may have been performed for the appropriate indication and in a technically perfect manner, patients are threatened by perioperative organ injury. For example, stroke, myocardial infarction, acute respiratory distress syndrome, acute kidney injury, or acute gut injury are among the most common causes for morbidity and mortality in surgical patients.”
The same article states, “a 30-day death rate of 1.32% in a U.S.-based inpatient surgical population for the year 2006. This translates to 189,690 deaths in 14.3 million (1 in 75) admitted surgical patients in one year in the United States alone. For the same year, only two categories reported by the Center for Disease Control—heart disease and cancer—caused more deaths in the general population.” Note this data was for inpatient surgeries.
The practice of anesthesiology is currently defined as “perioperative medicine.” At Stanford University, we’re called the Department of Anesthesiology, Perioperative, and Pain Medicine. Perioperative medicine refers to the care of patients before surgery (preoperative), during surgery (intraoperative), and after surgery (postoperative). Each of these three areas is critical in assuring the lowest rate of complications. The American Board of Anesthesiology requires each candidate for board certification to pass an oral exam with clinical questions pertaining to preoperative, intraoperative, and postoperative management. A board-certified physician anesthesiologist is therefore validated as an expert in all areas of perioperative medicine.
Who will make YOUR anesthetic decisions? Who will take care of you before, during, and after YOUR surgery?
Most anesthetics are conducted by physician anesthesiologists. At times, physician anesthesiologists employ certified registered nurse anesthetists (CRNAs) to assist them in what is called the anesthesia care team (ACT) model. In this model, an MD anesthesiologist supervises up to four CRNAs who work in up to four different operating rooms simultaneously. All the responsibility in the ACT model resides with the supervising MD anesthesiologist.
In a minority of states (19 of the 50 states) in America, governors made it legal for an unsupervised CRNA to provide anesthesia care. 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. https://www.aana.com/membership/become-a-crna/minimum-education-and-experience-requirements Physician anesthesiologists have to graduate from a four-year medical school or osteopathic school, and then complete four additional years of internship and residency to become board-eligible anesthesiologists. The initial rationale for unsupervised CRNA care was that some rural communities had inadequate supplies of MD anesthesiologists, so governors made the decision to let nurses supply the anesthesia care unsupervised. These states include Arizona, Oklahoma, Iowa, Nebraska, Idaho, Minnesota, New Hampshire, New Mexico, Kansas, North Dakota, Washington, Alaska, Oregon, Montana, South Dakota, Wisconsin, California, Colorado, and Kentucky. If you live in one of these 19 states, there’s no guarantee a perioperative physician anesthesiologist will care for you.
Does the lack of a perioperative physician—an anesthesiologist—make a difference? Yes.
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. Silber wrote, “These results suggest that surgical outcomes in Medicare patients are associated with anesthesiologist direction, and may provide insight regarding potential approaches for improving surgical outcomes.”
In 2009, in California where I live and work, Governor Arnold Schwarzenegger signed a law permitting independent practice for CRNAs. California physician anesthesiologists have been angry and concerned about this legislation change, but in the 12+ years since the law went into effect, the penetration of unsupervised CRNA practice in California was been minimal. This is despite the fact that there is an oversupply of CRNAs in the western United States.
The traditional older models of physician-only anesthesia or the anesthesia care team are still the dominant modes of practice in California.
Anesthesiology is the practice of medicine. Perioperative medicine is the practice of medicine. Anesthesiology and perioperative medicine are the domains of physicians.
When you are a patient in an intensive care unit (ICU), all orders and decisions are made by physicians. Nurses are an essential part of ICU care, but management is by physicians.
When you are a patient in an emergency room (ER), all orders and decisions are made by physicians. Nurses are an essential part of ER care, but management is by physicians.
Why should your perioperative medicine be managed by non-physicians?
A major conflict is playing out in American medicine at this time. Beginning in 2025, all CRNAs will need a doctorate in nurse anesthesia to enter the field. Expect these nursing graduates to introduce themselves to you as “Doctor.” This new degree, called a “Doctor of Nursing Anesthesia Practice (DNAP),” is not a medical school diploma, and by no means is equivalent to the Medical Doctor (MD) degree held by physician anesthesiologists. Medical school admission in America is extremely competitive. For the 2020-2021 year there were 53,030 medical school applicants, and 22,239 applicants were admitted, meaning only 42% of medical school applicants matriculated.
The American Association of Nurse Anesthetists (AANA) has made the decision to deceive patients by formally changing its name to the American Association of Nurse Anesthesiology, confusing the distinction between an MD anesthesiologist and a nurse anesthetist by adopting the word “anesthesiologist” to describe themselves.
The American Society of Anesthesiologists (ASA) released this statement: “The American Society of Anesthesiologists condemns AANA’s organizational name change and encouragement of its members’ use of the term “nurse anesthesiologist,” which will confuse patients and create discord in the care setting, ultimately risking patient safety.” The ASA statement also said:
- ASA, the American Board of Anesthesiology, the American Board of Medical Specialties and the American Medical Association affirm that anesthesiology is a medical specialty and professionals who refer to themselves as “anesthesiologists” must hold a license to practice medicine.
- The New Hampshire Supreme Court upheld a ruling in March 2021 by the New Hampshire Board of Medicine to limit the use of the term “anesthesiologist” to individuals licensed to practice medicine.
- The Council on Accreditation of Nurse Anesthesia Educational Programs defines “anesthesiologist” as a doctor of medicine (M.D.) or doctor of osteopathy (D.O.) who has successfully completed an approved anesthesiology residency program.
- The World Health Organization views “anesthesiology as a medical practice” that should be directed and supervised by an anesthesiologist.
Who will be taking care of YOU before, during, and after your surgery? As patients, you deserve to know, and you also deserve a physician managing your perioperative medicine.
Before your surgery, you deserve a medical doctor.
After your surgery, you deserve a medical doctor.
And yes . . . during your surgery, you deserve a medical doctor of anesthesiology as well.
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