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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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What’s the difference between a physician anesthesiologist and a nurse anesthetist? After the first 3 – 4 years in the workforce, either one can master the manual skills of anesthesia. That is, either one can display excellence in intubating the trachea, performing a spinal or an epidural anesthetic, performing a nerve block, inserting an arterial line, or inserting a central venous pressure catheter. There is no fork in the career path that makes a busy Certified Registered Nurse Anesthetist (CRNA) automatically inferior to a medical doctor anesthesiologist in hands-on skills. So what really is the difference between a physician anesthesiologist and a nurse anesthetist? The answer: internal medicine.

All physician anesthesiologists graduate from medical school, where they rotate through clerkships in surgery, pediatrics, obstetrics-gynecology, internal medicine, emergency medicine and psychiatry, as well as electives in surgical or medicine subspecialties of their choice.

By contrast, CRNAs are registered nurses experienced in intensive care or emergency room nursing, who then enter a 2 – 3 year program of learning the skills to anesthetize patients. CRNAs can now administer anesthesia independent of any physician anesthesiologist supervision in the majority of the United States.

The difference between a physician anesthesiologist and a nurse anesthetist is that the former has a depth of knowledge of 1) the physiology of the human body, 2) the pathophysiology of diseases, 3) the breadth of pharmacology, and 4) the ability to make diagnoses and prescribe treatment. In short, the physician anesthesiologist has extensive training in the internal medicine essentials of 1), 2), 3), and 4) above.

Nurse anesthetists are valuable and integral cogs in American healthcare. It’s not my intention to demean or minimize the role of CRNAs. My goal is to point out the most specific difference between a physician anesthesiologist and a nurse anesthetist.

At Stanford our department is named the Department of Anesthesiology, Perioperative and Pain Medicine. What is Perioperative Medicine? Perioperative Medicine is all the medical care before, during, and after surgery. Is Perioperative Medicine a subspecialty of internal medicine? In a way, it is. Following an internal medicine residency, graduates may subspecialize in cardiology, oncology, pulmonary medicine, kidney medicine, infectious disease, critical care, or . . . perioperative medicine. When I finished my Stanford internal medicine residency, the top four choices among my colleagues for the next step were: #1 a cardiology fellowship, #2 general internal medicine private practice, #3 an anesthesia residency, or #4 an oncology fellowship.

Stanford University now offers a combined internal medicine/anesthesiology residency, with the goal of training leaders in anesthesiology. The PGY1 year is spent entirely on medicine rotations. The PGY2 year consists of all anesthesia rotations. During PGY3-5 years, the resident alternates between 3 months of medicine rotations and 3 months of anesthesia rotations.

The outgoing Chairman of Anesthesiology, Perioperative and Pain Medicine at Stanford is Ronald Pearl MD PhD, an outstanding clinician and scientist who led our department for twenty-two years. In addition to board-certification in internal medicine and anesthesiology, Dr. Pearl is also board certified in critical care medicine. Dr. Pearl is one of the smartest clinicians I’ve ever met. His extensive internal medicine knowledge raises him above other anesthesia providers.

Currently, anesthesiology residency programs are three years in duration, beginning after a resident has completed at least one year of internship. During those three years of anesthesia residency (PGY2 – PGY4) the resident rotates through:

two one-month rotations in: obstetric anesthesiology, pediatric anesthesiology, neuro anesthesiology, and cardiothoracic anesthesiology
a minimum of one month in the adult intensive care unit during each of the three years
three months of pain medicine, including one month in acute perioperative pain, one month in chronic pain, and one month of regional analgesia/peripheral nerve blocks
one-half month in a preoperative evaluation clinic
one-half month in a post anesthesia care unit, and one-half month in out-of-OR locations.

These rotations of an anesthesia resident develop the young doctor into a clinician comfortable in preoperative assessment and management, in the intraoperative administration of anesthesia, and in the postoperative evaluation and treatment of patients.

Currently, internal medicine residency programs are three years in duration, including a one-year internship in internal medicine. During those three years (PGY1 -PGY3) a resident rotates through:

a minimum of 4 months of critical care (medical ICU or cardiac care unit) rotations
a minimum of 1/3 of Internal Medicine training occurs in an ambulatory setting
a minimum of 1/3 of Internal Medicine training occurs in an inpatient setting
a longitudinal continuity clinic of 130 one-half-day sessions over the course of training, including one clinic per month. The continuity clinic includes evaluation of performance data for resident’s panel of patients.
exposure to each of the internal medicine subspecialties and to neurology
an assignment in geriatric medicine
an emergency medicine experience of four weeks
electives available in psychiatry, allergy/immunology, dermatology, medical ophthalmology, office gynecology, otorhinolaryngology, non-operative orthopedics, palliative medicine, sleep medicine, and rehabilitation medicine

These rotations of an internal medicine resident develop the young doctor into a broadly trained clinician experienced in multiple areas.

I’m not advocating that anesthesia departments be folded under the umbrella of their institution’s department of internal medicine. Instead, what I am recognizing is that the field of anesthesiology is more than putting in breathing tubes, arterial catheters, IV lines, or nerve block needles in a variety of different surgical settings. The field of anesthesiology is understanding and managing medical problems before, during, and after surgery, i.e., Perioperative Medicine. Describing our specialty with the word “Anesthesia” is an oversimplification of what we do. If our specialty was newly named today, it would be called Perioperative Medicine, period.

What about pediatric perioperative medicine? Doesn’t pediatric perioperative medicine involve the knowledge base of pediatricians, instead of the knowledge base of internal medicine? Yes. Deep knowledge of pediatric medicine instead of internal medicine (on adult patients) applies to pediatric perioperative medicine. No doubt a pediatrician who then completes an anesthesia residency will likely be an outstanding pediatric perioperative doctor, but only 5.4 % of anesthesia care in the United States is on pediatric patients less than 15 years old. The majority of the knowledge base for anesthesia care pertains to adult patients, i.e. the knowledge base for internal medicine physicians.

Several examples will illustrate why internal medicine forms the backbone of perioperative anesthesia practice. Before surgery, a patient who presents with insulin dependent diabetes, hypertension, hyperlipidemia, and obstructive sleep apnea is an example of the kind of patient an internal medicine doctor sees regularly in his or her outpatient clinic. During surgery, a patient who develops atrial fibrillation or marked hypertension is an example of the kind of events an internal medicine doctor sees in an intensive care unit. After surgery, a patient who presents with chest pain or shortness of breath is an example of the kind of patient an internal medicine doctor sees in the emergency room or in the intensive care unit. Wait . . . you can argue that a CRNA has previous experience working as a registered nurse in an ICU or an emergency room before beginning nurse anesthetist training. But a registered nurse in an ICU or an emergency room does not independently diagnose and treat medical conditions. A registered nurse in an ICU or an emergency room follows written orders from a medical doctor. There is a world of difference between a medical doctor commanding diagnosis and treatment in an ICU/emergency room versus a registered nurse who follows orders.

Should all anesthesia residency training follow the Stanford optional model of combining internal medicine and anesthesia residencies into one program? No. Prolonging the training of every physician anesthesiologist in the United States makes little sense, but those who desire to be leaders will consider this double-residency option.

Recent years brought an attempt to rename the territory of anesthesiologists as the “Perioperative Surgical Home.” The Perioperative Surgical Home is defined as “a patient-centered, team-based, and coordinated perioperative care setup, composed of the head anesthesiologist-perioperativist in tandem with dedicated nurse practitioners and other PSH team doctors.” This is a move in a positive direction, with the intent of better patient care coordinated by an anesthesiologist-led team. There is an economic barrier to the Perioperative Surgical Home, in that the PSH may appear to be a coup attempt for anesthesia departments to take over jurisdictions from preoperative and postoperative internal medicine doctors. Any adoption of the PSH will likely be gradual, as the battle for patients plays out in each medical center.

Instead, a first step is that anesthesia departments redefine themselves as Departments of Perioperative Medicine, and that the academic training for these departments involve increasing time spent expanding the internal medicine knowledge base of residents in medical intensive care units, cardiac intensive care units, medicine wards, and medicine clinics. Performing month after month of repetitive intraoperative anesthesia care has a decreasing return on expanding a resident’s fund of knowledge, and can serve to make the role of a physician anesthesiologists and the role of a nurse anesthetist close to being the same.

It’s important that physician anesthesiologists create perceivable differences between themselves and CRNAs. The role of Perioperative Medical Doctors is a more broad and more specific identity when compared to what nurse anesthetists do. Let’s make our young physician anesthesiologist trainees into Perioperative Medicine Specialists, instead of confusing them with other anesthesia professionals who can also administer propofol, sevoflurane, and rocuronium.