As a practicing orthopedic surgeon in Show Low, Arizona, I have dedicated my life’s work to improving both the quality of and access to care in rural Arizona. SB 1336 will not improve rural access or care anywhere in Arizona.
First, SB 1336 creates a patient safety issue. If the bill goes forward in its current form, the standard of physician direction of patient care, which provides a necessary safety net for the patient in the operating room, would be removed. This is dangerous for Arizona patients. It has nothing to do with increasing access to care as proponents of the legislation claim.
Altering the definition of direction will not mean there are suddenly more Certified Nurse Anesthetists (CRNAs) living and practicing in rural areas. CRNAs are utilized to provide anesthesia for patients who are undergoing procedures performed by a physician; thus there is always a physician when a patient is administered anesthesia, for it is the physician who performs the procedure. If there is no physician, there is no procedure and no need for a CRNA. Saying this bill would increase access to care is simply not true.
The system currently in place works well just as it is. I provide care for my patients in the operating room, frequently in conjunction with a CRNA’s services. My patients expect that I, as the surgeon with whom they have built a relationship and trust, will be in charge. A surgical patient generally only meets the CRNA once, on the day of his or her procedure.
SB 1336 erodes safe patient care. When a crisis occurs – and while infrequent, unfortunately sometimes do – it is critical to recognize the cause of the problem and take corrective action. It is the physician who has been trained to take charge and handle the situation causing the emergency. Physician direction is a must for our patients. This bill will create a problem with regard to who is really in charge, the doctor or the CRNA. A seemingly small change in statutory language can make all the difference to a patient who no longer has a physician personally responsible for his or her overall care.
To prepare for the decision-making required to medically address life and death emergencies, physicians like myself undergo years of intense, formal, post-college medical education and residency training. Medical school and residency establish standards of clinical training that is commensurate with the responsibility of making irreversible life and death decisions. After medical school, I had five years of a surgical residency with call every other night, followed by a trauma fellowship participating and training in thousands of surgical cases prior to entering private practice.
While advance practice nurses like the CRNAs are an essential part of the care team, their education is not designed to prepare them for the many aspects of evaluating, diagnosing and treating a patient that can be required, especially in an emergency situation.
The best surgical outcomes demand a highly qualified, intensely trained, experienced individual responsible for the patient during surgery. Patients deserve to undergo a procedure with a designated leader trained to supervise the team. To achieve optimal surgery outcomes, the team must be coordinated and led by a professional with the education, training and skillset to act at the highest level and that is a physician.
SB 1336 is a step backwards in patient care. Rural and urban Arizonans alike deserve health care delivered by those who have been extensively trained in the broader practice of medicine. Rural citizens like my neighbors in Show Low will not accept marginalized care.
SB 1336 would erode my ability to direct the management of my patients’ care. It fragments the effectiveness of the health care team. It doesn’t make things better – it makes things worse. It is dangerous for our patients.
Ronnie Dowling, M.D. is an orthopedic surgeon at White Mountain Surgical Specialists in Show Low.
The views expressed in guest commentaries are those of the author and are not the views of the Arizona Capitol Times.