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Arizona’s opt-out eliminates physician safeguard during surgery

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As a physician anesthesiologist, I’m a physician first and an anesthesiologist second. I’m not only responsible for delivering anesthesia and ensuring my patients do not feel pain during their procedure or surgery, but also, helping ensure that my patients make it out of these procedures alive. 

That might seem like a strong statement, but many people don’t realize anesthesia and surgery are inherently dangerous. During a procedure, I monitor every heartbeat, the patient’s blood pressure, breathing and other vital signs. But even in routine procedures, complications occur and those vital signs can change instantly – threatening the patient’s life.  

My education and medical training as a physician have prepared me to know exactly what to do when the heartbeat stops, blood pressure falls to a dangerous level, or any other medical complication occurs. I instantly identify and diagnose the problem and direct the surgical team to pause what they’re doing if needed, so we can ensure the patient is safe. Once the patient is stabilized, the surgery can proceed and the patient returns to the arms of their loved ones. 

Gov. Doug Ducey’s recent decision to opt-out of the Centers for Medicare & Medicaid Services’ accreditation standard for hospitals and other settings eliminates the longstanding requirement for physician supervision of nurse anesthetists, even though 80% of Arizona voters overwhelmingly want a physician managing medical complications or emergencies during surgery.  

Heidi Tavel

Heidi Tavel

Ducey’s decision was made without input from the public or the state’s medical community and risks patients’ lives – and for no reason. Eliminating physician supervision and allowing nurses to administer anesthesia without physician oversight results in zero cost savings for patients as Medicare, Medicaid and most third-party insurers pay the same fees for anesthesia whether administered by a nurse anesthetist or physician. It simply lowers the standard of care for patients.

Our governor has dismantled the highly successful anesthesia care team model and will now allow nurses to administer anesthesia without physician involvement. For some patients, this can mean the difference between life and death – something I see all the time. 

I recently had a very healthy man in his early 60s undergo a routine outpatient procedure to repair a hernia. He was a rancher, worked in the hot Arizona sun and had not experienced health issues. Theoretically, this should have been easy for him and the surgical team. However, while he was on the operating table, he had a massive heart attack that would have killed him instantly if it had happened at home. This was confirmed by a cardiologist after the procedure, who found the patient had a life-threatening narrowing of a vessel going to his heart, known as the “widow maker artery.” But just minutes after experiencing cardiac arrest and having no pulse during his outpatient procedure, we got his heart back to a normal rhythm, and he survived to return to his family. 

Without physician involvement in his anesthetic care, I can’t say this patient would still be alive today. Physicians are medical experts with up to 14 years of post-graduate medical education and residency training, including 12,000 to 16,000 hours of clinical training, so nearly twice the education and five times the training of nurse anesthetists. 

Our residency is called a residency on purpose because for four years, we practically live in the hospital, actively participating in an accredited medical program and on a gradual basis, demonstrating our ability to safely practice medicine without other physician oversight. We are at the hospital day in and day out, working so many hours that we put our lives on hold. We sacrifice spending time with friends, family and traveling — the things that many people in their late 20s and early 30s do, because we’re putting in all of our time and effort into learning how to keep people alive. And we do it with no regrets, because it is our calling.  

Just as you would not remove the surgeon (a physician) from the operating room during a surgical procedure and allow a physician assistant to operate alone, what sense does it make to remove physician involvement from the patient’s anesthesia care and allow a nurse to perform alone? 

Community members, lawmakers, people of Arizona, I beg you to ask yourselves: who do you want in charge of your anesthesia care? If it was your family member, your child, your spouse, your parent – would you want a physician in charge of the anesthetic care, or a nurse working alone? Call the governor and demand he rescind his decision to remove physicians from the anesthesia care team. 

Heidi Tavel is an anesthesiologist practicing in Tucson.

19 comments

  1. I assume nurse anesthetists will be held to the same standards (in court, and by their hospital) as a physician should something go wrong?

    What’s that? Nurses can’t have physicians testify against them because they’re different professions? So… I’m sure the nurses will hold each other to the same standards as physicians are held, despite a fraction of the training… And a lack of a comprehensive medical training…

  2. Just a buncha sad little anesthesiologists who are crying like babies because they went to school for stuff that has nothing to do with anesthesia, wasting all that time and money and CRNAs didn’t have to. Oh and because we are taking their jobs as we are more cost-effective for patients and hospitals!! You don’t need MD after your name to give anesthesia and keep the patient safe. CRNAs have been practicing for a long time without an anesthesiologist being there so what is the problem? Oh, wait it is an ego thing. Stop fearmongering and do your jobs without whining about me doing mine in the capacity that I was trained too! You act like we are trying to perform surgery or something! Nurses were the first anesthesiologists! Go and be real doctors and leave the anesthesia to us.

  3. Fear-mongering Doctor. Shame on you. It is disheartening to read a professional is degrading other medical professionals. Dr. Tavel fails to address that there isn’t ANY difference in care provided from Certified Registered Nurse Anesthetists (CRNA’s). CRNA’s are board-certified to provide anesthesia care to patients just as medical anesthesiologists are. And CRNA’s give a value-based advantage to the healthcare system through lower costs. Power and money, which medical anesthesiologists do not want to give up, is what this is all about. The evidence is in CRNAs favor; you make your OWN choice.

  4. Ask your surgeon who he/she asks for when their family members get surgery. Its always an MD/DO, not a nurse. Why should other patients be any different? I’d rather have someone with 20,000 hours of training rather than someone with 1,500.

  5. Dear Aaron and Momo,

    You can go ahead and trust yourselves and your loved ones on the hands of someone who had 2-3 years of superficial training. Physician anesthesiologists go through vigorous years of training and most importantly experience to manage every possible complicated case. CRNAs may be able to handle independently anesthesia in uncomplicated cases such as tooth extractions. However, for anything else, MD should supervise. Next thing we know heart transplants will be done by NPs without supervision.

  6. Wow

    Could this title be more deceptive?! Hardly professional and most certainly designed to fear monger. Quite the low bar for my physician colleague here frankly.

    1) Every surgery is performed by a physician. A dentist, a podiatrist, an MD or a DO etc. So there is never a time when a physician anesthesiologist (MDA) , a Dentist Anesthesiologist OR a Nurse Anesthesiologist (CRNA) IS NOT working with and collaborating with a physician.

    2) There has NEVER been a requirement for CRNAs to work with MDAs anywhere in the country including AZ, so this is not a change.

    3) A recent study in AZ found that 70% of all CRNAs DO NOT work with MDAs and nothing changed the day after opt out than the day before in how anesthesia operates in AZ. INCLUDING the standard of care in AZ which is the same as it was.

    4) In 150 years of being studied, outcomes being measured and your trade org desperately trying to do so, there has NEVER been a SINGLE study showing any difference in morbidity & mortality (outcomes) showing MDAs or MDA involvement in anesthesia care has any impact. CRNA outcomes are equivalent. I have much respect for my well training physician colleagues and count many as friends but the fact is there is no difference no matter how your trade organization may want to manipulate the years and training hours.

    5) This changes nothing in regard to safety or outcomes. Now Hospitals and other facilities are now FREE to choose whatever model they feel works best in their facility without burdensome irrelevant barriers to doing so. All CRNA, All MDA or a mix they get to decide and make the best choice for them.

    Instead of making up some nonsense about the standard of care will decrease in order to fear monger and deceive the public and legislators, let us be honest. The CMS rule existed for HOSPITALS to bill CMS their facility fees. Not for me, a CRNA, to bill independently for my anesthesia fees. It does not create liability, responsibility or control of the operating practitioner over the CRNA. It does not require an MDA to have ANY involvement in anesthesia care. It is arbitrary and meaningless.

    What this represents is removing another anti-competitive barrier to free market competition in AZ. One which CMS itself has acknowledged is neither based in science or evidence. Just an arbitrary “rule” for hospitals to bill medicare which gives a competitive advantage of one group over the other.

    This opens the market for equal providers to provide anesthesia services without the constant fear mongering from your trade org which is intended to scare surgeons and facilities from using CRNAs. If you believe your service is better and worth the extra cost, then you should be willing compete on a level playing field in the MARKET. Not use deception and fear mongering to try and win. It is disappointing to witness honestly.

    #TDL

  7. I almost died under the care of a CRNA at a surgery center. I was released way too early. On my way home, I passed out and stopped breathing and had to be rushed to the ER for resuscitation.
    I’m sure a physician anesthesiologist would have been able to recognize that I was much too sedated and wasn’t quite ready to be discharged.
    Never again.

  8. A brief perusal of the independently-funded studies supports Dr Tavel’s concerns.
    “Went to school for stuff that has nothing to do with anesthesia” means they learned about the WHOLE HUMAN BODY and everything that can go wrong within it.
    Let’s use a flight simile.
    Physician = trained pilot; CRNA = flight attendant.
    Both are trained well for what they do.
    If everything is going right and smooth, OK, a flight attendant can hold the yoke and keep the plane level.
    If things go wrong in any way, you want someone who’s trained to crash-land the plane.
    Do you want that to be the flight attendant, or someone with more know-how?
    – A Physician

  9. Careful what you wish for CRNAs… With independence come culpability.

    Also, cavemen were there first architects, building lean-tos… What’s your point?

  10. First off. You do 4 years of residency, 1 year of that is being an intern with 1-2 months of anesthesia. Then you do 3 years of anesthesia training. During that time you are let out by 2-3 pm to go to an hour lecture before going home for the day. Your hours of clinical time are counted from the time you enter the building til the time you leave regardless if you were actually involved in doing anesthesia. Also, during your residency you can count starting a case but not staying around until it is finished as completing the entire case. Do you work in a medical direction model? Where you run more than one room? Then you aren’t monitoring every heart beat of every patient. The Epstein study already showed that in first case starts an anesthesiologist running 2 room was only able to complete all 7 TEFRA tasks they need to do to get reimbursed by Medicare 35% of the time leaving the other 65% of case open to Medicare fraud. You’re not there all the time unless you are doing your own cases. But CRNAs also provide anesthesia, 55,000 CRNAs provide anesthesia across the country and the rate of adverse outcomes is the same for anesthesiologists and CRNA. So leave the economics of how this is encroachment in you $500k salary out of it and realize that we are all here to serve our patients. They are safe wether it is a physician anesthesiologist or a nurse anesthesiologist. We are all here for the betterment of our fellow man.

  11. Thank you for such a well written piece and for speaking up. I can see why some people don’t value the training of a physician because they don’t fully understand the physiology behind everything. They don’t know what they don’t know, I guess. The over-confidence will also make them more dangerous. In the end, patients will suffer.

  12. As a CRNA myself I have some concerns about the passage of this law. I had the opportunity to apply for medical school but specifically chose not to because of the time and cost it takes to become a physician. I also do not want the legal responsibility that physicians shoulder. I am a confident in my skills as a provider, but I specifically made the choice not to pursue the significantly more rigorous education and training that it takes to become a physician anesthesiologist. I am always grateful to know that I have top cover from these individuals and removing them from the equation will without question be detrimental to a subset of complex patients.

  13. A CRNA on my case did not have the skills when my simple case went south. Thank God a physician was available to address the issue.

  14. I don’t have much to say about the article itself, but as a proponent of transparency in health care, we need to correct some of the above commentary information for the sake of clarity and accuracy:

    1. An anesthesiologist is an MD or DO. There is no other set of letters to accurately denote an anesthesiologist’s credential.
    2. A CRNA is a nurse anesthetist. There is no other term that accurately describes that credential or role.
    3. The term anesthesiologist is a term to uniquely designate a physician who matriculates from medical school and trained in a residency program in Anesthesiology. Just as there is no such thing as a “nurse cardiologist” or a “nurse obstetrician”, there is no such thing as any type of “nurse-ologist”. If one wants to designated themselves an anesthesiologist, there is a clear path to do so: medical school and residency.
    4. I know dentists have self proclaimed themselves “dental anesthesiologists”, but that is a false term, implying a depth and bredth of anesthetic knowledge they simply do not possess. I sure wouldn’t want them caring for me under anesthesia. They can stick to cleaning my teeth, thank you.
    5. Finally, in any type of anesthetic emergency, a surgeon or proceduralist of any type wouldn’t know the first thing to do. They do not even have the basic airway and access training of CRNAs. Many don’t have ACLS and PALS certifications. That is not a safe supervisory model and I’m surprised and concerned it exists.

    When there is a critical emergency in my hospital’s operating rooms, I see several CRNAs and multiple anesthesiologists working together to save a patient, each with their own roles and skill sets. I support a team model; I know the dangers of what can happen during surgery, and I want a physician—an anesthesiologist—supervising my care.

  15. Dr. Daniel D. Wert

    I had a very enjoyable CRNA anesthesia practice for around 9 years. I then went to medical school followed by a residency in anesthesia. As a physician anesthesiologist I was able to enjoy various aspects of my practice that I wouldn’t have been able to as a CRNA. I served as the Anesthesia Department chairperson for the last 14 years prior to my retirement. We had an excellent team practice that included CRNAs and physician anesthesiologists. For 20+ years during retirement I have enjoyed very much participating in more than 60 volunteer international medical missions to many different countries. I have also enjoyed being a part of the four year anesthesiology residency program in the country of Honduras. We have graduated over 100 anesthesiologists during the past 20 years. So I am giving this information to share that the anesthesia practice of a physician anesthesiologist often expands to other areas as well as providing excellent clinical anesthesia care to patients.

  16. This is an old problem that has been solved. Physician anesthesiologists have at least double the education plus usually 10x the clinical training of CRNAs. To reflect the patient outcomes of the experience gap between anesthesiologists and CRNAs, when anesthesia was provided without physician anesthesiologist involvement, the death rate within 30 days increased to 2.5/1000 excess deaths and the failure to rescue rate increased to 6.9/1000 excess deaths. (Anesthesiology 2000; 93(1) 151-163: ASA Monitor May 2015 Vol 79 Number 5 p 60-61). Many separate studies also reveal that 80- 92 % of participants would want a physician anesthesiologist directing their care if given a choice.

    The opt-out states did not see an increase in access to care at all. Rather, the opt-out states had the same access and yet higher costs of inpatient care (8.7% or 1800 dollars more) due to independent nurse anesthetists taking longer to perform the same services as physician anesthesiologists and having worse outcomes in terms of complications requiring additional treatment. (Health Econ Rev 2017;7:10)

    The World Health Organization (2018 WHO- WFSA) states anesthesia is complex and hazardous and its administration requires a high level of expertise in medical diagnosis, pharmacology, physiology, and anatomy. We take your care seriously. Please reflect on the words of Dr. Shillcutt in her article, “We are anesthesiologists. We got you.” https://www.kevinmd.com/blog/2019/09/we-are-anesthesiologists-we-got-you.html As she says, “Why do we do this? For you. Period. It is an honor to care for you.”

  17. Joan Rivers died under the solo care of an Anesthesiologist

  18. Anesthesia is no joke. I would want a doctor caring for me during surgery. I bet most patients agree with me. Gov. Ducey should listen to the physicians.

  19. Lets get to the bottom of this matter. Ducey took it upon himself to address this issue without any input from, the patients, the insurance companies, the hospitals, the actual medical professions. Or for that matter the state legislature. Why? What was his motivation? What say you Gov Ducey?

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