Wednesday, August 11, 2010

Doctors or Technicians?

Interesting article recently from Health Affairs (via WSJ blog) about the clinical equivalence between the care provided by anesthesiologists and CRNAs. The article concludes by advocating that CRNAs be given permission to practice anethesiology without physician supervision. It's more cost effective. And there is no compromise to the quality of care delivered to patients.
We recommend CMS return to its original intention of allowing nurse anesthetists to work independently of surgeon or anesthesiologist supervision without requiring state governments to formally petition for an exemption,” they conclude. “This would free surgeons from the legal responsibilities for anesthesia services provided by other professionals. It would also lead to more cost-effective care as the solo practice of certified registered nurse anesthetists increases.” The study was funded by the American Association of Nurse Anesthetists.

A couple of caveats. One, the study was conducted by the American Association for Nurse Anesthetists (sort of like a study claiming that Jeff Parks is the smartest man on earth being conducted by "friends and family and hired sycophants of Dr. Parks"). Also, the study admits that CRNA's tend to work on less complex cases than MD anesthesiologists.

The main thrust of papers like this is to delve into the essence of what it means to be a "doctor". Are all doctors alike? Is the orthopod who replaces 350 knees a year the same as the internist cranking through 30 patients a day with complex medical problems? Is it fair or unfair to further categorize the various specialities according to some sort of intellectual hierarchy? Do some specialties verge perilously close to being mere technicians, thereby inviting the sort of turf war salvo sounded by the above referenced paper?

In reality, I think it goes beyond anesthesiology (although anesthesiologists are an arguably easier target). Most of the work done by a family practitioner can probably be adequately performed by a NP or PA without adverse effects. If you trained a physically gifted person to take out gallbladders and that's all he did, day after day, I bet you would be able to find a paper demonstrating that the non-MD surgeon has a similar complication rate as a formally trained general surgeon. But then what is that automaton going to do when he encounters a cholecysto-colonic fistula or when the cholangiogram shows he has cut the common bile duct? What is the NP going to do when she has to manage a patient with diabetes, heart disease, peripheral vascular disease, and obesity who comes into the office with abdominal pain? Would any CRNA accept the responsibility and stress of running a CABG solo?

The bottom line is, most of the time you don't need a doctor until you really need one. But you never know when that day is going to be. You never know when that seemingly normal patient who walks into the ER ends up turning into a complete disaster. My advice to these non-doctors seeking legitimacy and complete autonomy: be careful of what you wish for.


ER's Mom said...

I'm an OB. I tell patients 95% of the time, I'm an overpriced cheerleader. But that last 5%...

I'm worth it.

Anonymous said...

"What is the NP going to do when she has to manage a patient with diabetes, heart disease, peripheral vascular disease, and obesity who comes into the office with abdominal pain?"

Yeah, of course Buckeye, I totally agree with most of what you say, but if you are talking NP, I'd rather have an NP who has 10 under her belt in MICU/SICU somewhere in her past who has decided to slow things down a bit and practice office medicine, than some docs. Just depends.

Diabetes, heart disease, peripheral vascular disease, and obesity who comes into the office with abdominal pain? This stuff is on the daily menu for many nurses. She's gonna have been in the trenches, has top notch assessment/intuitive skills, fears no evil, probably had the ear of those docs who came in and signed behind her for years before she got her NP... and most importantly she knows which surgeons know their stuff. I tend to want to know what her gut says.

Of course, there are those who skip the trenches... I navigate around those types no matter what level they are.


Anonymous said...

lol lol
SCRN, you know what the ICU NP does in my hospital? She weans people of vents. That's her job doing sprint protocols. She also disappears at 17:00 for the day and has weekends off why the residents/attendings manage her patients. She also consults on a whim. I would not trust her anywhere near a clinic outside her protocol driven job where she has to think outside her box. It is a dirty little secret but your typical graduating IM resident is well trained to be a hospitalist not an outpatient internist. A busy outpatient clinic is not "slowing down". As someone who has worked extensively in the clinic, ICU, and floors frankly the hardest job of the three is the outpatient clinic. I say that as geezer who was running codes and managing crashing patients way back when you were thinking about your first career. You are suffering from you don't know what you don't know syndrome.

Anonymous said...

Damn, Buckeye don't blame me when you end up at the bottom of whatever that lake is in know, the one that caught on fire back in the 60's.
For givin away all our secrets...
And as rediculous as it sounds, I started off as a Surgical Intern, even did a few Appys, and one of those Old-School Gallbladders with an incision I oould have crawled into and taken shelter if a tornado hit during the case...
See, I was in what was called a "Pyramid" program, sort of like one of those "Pyramid" ripoff deals.. I was one of the ones who lost there money.:(
and bein lefthanded didn't help...YOU try operating from the other side of the table.
and there was the time one of my eyeglass lenses popped out into an open chest, Aortic Valve replacement I believe, and did you know plastic lenses don't show up on X-ray very well???
in fact I was lucky to get a
2d year Anesthesia spot, they needed a token English speaker..:)
and Anesthesia was only 2 years after Intership, so just about the time I'd figured out how to work the vaporizer, I was done...

Frank "put it in the whole that looks like a vagina, not an anus" Drackman

Anonymous said...

Anon 9:30
I just cannot help who ya'll hire. I am sure there are enough of (if you read my post) "...those who skip the trenches... I navigate around those types no matter what level they are." I know you probably want to do that whole mid-level provider rant thing. But it's old and tired. And, seriously, I'm not gonna "stroke-it" for you. You can fight that out with someone else.

I'm interested in anybody who is good at what they do.


Lumen said...

This is a ridiculous argument that has been going on for ages and will not be settled anytime soon. Full disclosure I am a physician assistant in vascular surgery with a long career in gen/trauma surgery.
The fact of the matter is every patient wants the best provider that they can get in that situation. It will not always be a doctor who is available and our system has now provided alternatives such as PAs, NPs, CRNAs. I have seen great Doctors (MD and DO), PAs, CRNAs etc and I have seen shoddy ones. I can't count the numerous examples of times I have been called by an ER DOCTOR who doesn't recognize a chronically ischemic leg or an acutely ischemic leg. How many times have I asked do they have a femoral pulse and been put on hold as they run off to check the most basic of physical exam features. This is not limited to Drs but to PAs, NPs etc. I could give other examples of the times I have had to place the arterial line for the anesthesiologist since they have flailed away and produced hematomas.
I would argue the doctors I work closely with value my opinion and hard work in our collaborative practice and the majority of the patients that I see inpatient, interoperatively and postoperatively are happy with the care they receive. If they are not happy or want to see the surgeon not only do I get the surgeon there, but I make sure they are seen as soon as possible by the physician. Above all I value the physicians in our practice and the skill set and knowledge they bring that allow us all to thrive. If I am unsure with something they are either available in person or by pager. Without them there would be no me.
Finally, the fear of the "other provider" is due to the fact of job security, but more rightly it should be focused on quality control and making sure we are all providing the best care we can for all patients. PAs, NPs, CRNAs are not going to disappear. They exist because there is a need in our current healthcare system. While my personal bias is towards a PA/MD/DO model of training I do feel there are good CRNAs and NPs and our focus should be on insuring the best quality of education and training for everyone. Finally, for those who are not up to snuff make sure to be vigilant around them and if necessary report abuses.

My four and half cents,

Anonymous said...

Can you come help me do an Arterial Line?


You CANNOT make a claim like that and not back it up... Its like me sayin an Internist needed help writing prescriptions...

It's not that I don't believe you, I just wanta know who it was.

Frank "Can start an A-line while jerking off" Drackman

tom said...

many good comments-I especially like the idea of "don't know what you don't know". That observation has no licensing limits.

I also like the comments on the value of experience-Imagine 2300 hours on July 1 in the Cardiac Surgery ICU-who would your rather have opining on your falling blood pressure, the nurse with 10 years experience with hearts or Dr. Newby?

Reality check folks- we do not have the workforce needed to do the work that exists today-this will only worsen as Obamacare(More poor paying Medi-Caid} shows up. And while I can not prove this I do not beleive Americas best and brightest are pursuing careers in medicine.

My first ah ha that the best and brightest are seeking other careers? Half asleep on a guerney waiting for a c-section to get going and hearing the attending ask a couple of the residents "what congental cardiac anomolies would you be thinking of if this baby comes out blue and stays blue? Silence... Then a hint is offered "they all start with T" More silence followed by a rather timid 'persistent fetal circulation?"

The demand for NP's/PA's will grow, and their roles likely expand, but not to the point of independent practice here in CA. The challenge will be how to effectively manage those roles.

Anonymous said...

Tom--- I would like to believe that you are not basing your view of the medical profession on your sedated experience on that gurney. Medical school was and still is pretty damn competitive. The only difference is that the "best and brightest" often don't want to go into primary care which pays nothing and is slowly being outsourced.

Michael Kirsch, M.D. said...

Leaving aside the substance of your post, no one guards their turf more aggressively than anesthesioloigst. If Demerol were developed today, these guys would insist that only they could administer it for conscious sedation. The reason? Patient safety, of course.

Resident Anesthesiologist Guy (RAG) said...

It's like anything else - there's good and bad on both sides regardless of the training. I have several CRNAs that I love to work wtih and WILL ASK FOR THEIR ADVICE on cases where I'm not as familiar, etc. Of course there's also some bad ones that I've wondered how in the hell the patient hasn't coded.

I will say, at least in my program where we train a large number of SRNAs, that there seems to be a widening gap between the MD-residents and SRNAs. Even talking to some of the older CRNAs it's becoming concerning to see how and what is being allowed in to CRNA schools currently. I personally think that in a decade or less we'll be able to see the differences because the CRNA schools have been flooding the market, have decreased their admission requirements, and are putting out some very poor anesthetists (along with some very good ones as well).