Douglas R. Bacon, M.D., Editor

Perpetual Motion

here is a “bridge” that connects our offices in the Mayo Clinic’s Charlton Building to the operating room suite in the Methodist Hospital. From the first floor, the walkway overlooks two stories to a subway waiting area for radiation oncology and a walkway to the Gonda Building. The waiting room often hosts musical groups, ranging from full choirs to small chamber groups, most often at lunchtime. Hearing these programs is one of the pleasures of walking back to the office between cases.

Late one afternoon, however, a solo instrument was playing. Deep, resonant tones played a song instantly recognizable to the ear of any parent of a child studying the Suzuki Method: “Perpetual Motion.” The crisp, precise music made me stop and look down. A lad of no more than eight years was playing his quarter-sized cello. Passersby on their way between the subway levels of Charlton and Gonda had stopped to listen as well. When he finished, his mother and two younger brothers came to his aid, packed the instrument and music away and continued waiting for their loved one.

As the father of four sons, all of whom either play or played stringed instruments and learned via the Suzuki Method, this interlude brought back a flood of memories. The most recent was that of my youngest son conquering the intricacies of “Perpetual Motion” and the pride he took when he moved on to his next musical challenge. I also remembered the professor of cardiology who taught heart sounds to my class in medical school and how he used a symphony to show how the different sounds could be teased apart, yet together made a beautiful whole. The heart tones, he assured us, were very similar.

So, dear readers, how does this relate to anesthesiology?

We are a part of the complex health care delivery system that, when functioning properly, is like the sound of a beautiful symphony. Often I have thought that anesthesiology was the most melodious part, but lately I have come to believe that we are more like the baritone section. We are there to support the music around us, very rarely given a solo part, and are overpowered by the more “glamorous” instruments around. What is lacking in American health care, however, is a conductor. While the American Medical Association (AMA) aspires to the role, it has had difficulty convincing baritones, violins and all the other instruments alike that the symphony is worth their individual input. AMA tries to deeply care about all physicians, or members of the orchestra, but often cannot respond to the needs of each instrument. Because there is no recognized support system for the orchestra, the needs of the group are often left to chance. Other players come forward to compete, to fill in gaps as they see fit, and fail to harmonize with either the music or the group.

The most telling of these recent competitions in health care is from the American Association of Colleges of Nursing (AACN). AACN plans to convert its advanced-practice nurse degree from master’s programs to “Doctor of Nursing Practice” (DNP) by the year 2015. This means that all advanced-practice nurses, including nurse anesthetists, having been awarded their DNP will earn the right to be called “doctor.”

This is a large dissonant note in health care and one that the House of Medicine needs to address head-on. At the same time, we will have to proceed cautiously in full accord with past Federal Trade Commission (FTC) dictates. ASA in the late 1970s and early 1980s came to an agreement with the FTC over just such an issue. The FTC was concerned that ASA was restricting the practice of nurse anesthetists. Using its powers and the possibility of a lawsuit over restraint of trade, the FTC entered into an agreement with ASA whereby ASA would not restrict in any way the relationship between anesthesiologists and nurse anesthetists, nor would it regulate the supply of either group. Thus, under ASA’s current Bylaws and by this settlement, ASA cannot enter into the health care provider market; nor can it regulate either residency training or schools of nurse anesthesia.* Thus ASA is effectively prohibited from taking any action against members for their participation in the education of residents or nurse anesthetist students.

For patients or those listening to the health care symphony, the granting of the DNP to advanced-practice nurses may be as disconcerting as the baritones playing roles assigned to the violins. Assuming that the quality of care rendered by individuals with a nurse doctoral degree is not equivalent to that of a physician and that these health care providers would identify themselves to patients as “doctors” — thus creating confusion, jeopardizing patient safety and eroding the trust inherent in the true patient-physician relationship — there will be further fragmentation of care and more resentment against the health care delivery system. If patients are led to believe that they are receiving care from a “doctor” who is in reality a DNP rather than a physician, many of the trust issues in health care could worsen.

AMA is taking this issue very seriously. At the June AMA House of Delegates Meeting, there is likely to be at least one resolution on this topic. It is incumbent upon the House of Medicine to unite and play the same music if there will be any guarantee that patient care will not be adversely affected. Will AMA turn to the ASA delegation for help and advice? Undoubtedly, for we have had the longest experience in dealing with advanced-practice nurses. Yet that history clearly demonstrates that it may be impossible to contain this issue, in much the same way it has proved difficult to stop advertisements for “nurse anesthesiologists” or to question the qualification of nurse anesthetists to manage pain or intensive care unit patients with the skill and diagnostic acumen of the anesthesiologist, despite their protestations to the contrary and the clear limitations of state scope-of-practice laws relating to nursing.

How should we proceed?

With much effort and personal commitment, preserving the value of quality medical care will be sustained. First and foremost, we must act like physicians in dress and decorum. Anesthesiologists, surgeons and internists need to remember that they are physicians — and being a physician comes with societal expectations that only we, by education and training, can fulfill. Like the orchestra, we must tune to the concertmaster and play the same music as a united orchestra, in proper concert attire. We cannot afford to argue, as many professional athletes have, that we did not ask for society to hold us in such high regard and therefore refuse to meet these expectations. For most of us, we aspired to become physicians and knew that there would be a lot of hard work, but we persevered because the rewards, among them the respect for the profession as a whole, were important. Quite simply the DNP might well be imitation, the very highest form of flattery and a quest by the nursing profession to be held in the same esteem as are physicians with similar responsibilities, including those related to liability.

Secondly, maintaining the integrity of medicine and anesthesiology will be costly in many ways, but most assuredly it will be costly financially. ASA and component members need to contribute to their political action committees (PACs) heavily over the next few years, both in our specialty and in the more generic state and national medical society PACs. It is quite likely that the debate will take place at the state level, and boards of medicine and nursing will craft regulations that address clinical situations with DNP-holding nurses. To have input, we need to be a part of the process — which means both participation and dollars.

Just as “Perpetual Motion” is one lesson in mastering a string instrument using the Suzuki Method of instruction, so we must take to heart the reasons why AMA was formed in the 1840s — partially as a response to the various sects practicing “irregular” medicine. The triumph of allopathic medicine owes much to science, but it also is indebted to the AMA that worked with government to orchestrate laws and regulations that in the end favored the allopaths.

Now is the time to come forward and join the symphony — as musicians playing with all our might or as patrons supporting the musician’s efforts. Without this exhortation, there may be no beautiful music in medicine in the days to come.

— D.R.B.

* Smith BE. The 1980s: A decade of change. In: Bacon DR, Lema MJ, McGoldrick KE, eds. The American Society of Anesthesiologists: A Century of Challenges and Progress. Wood Library-Museum of Anesthesiology Press. 2005:173-191.




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