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Douglas R. Bacon, M.D., Editor
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Confessions of a Hockey Dad
 nlike
soccer moms, we hockey dads are not generally recognized
as a political demographic group. We are better known
for being crazy, perhaps with some justification.
Who else would haul his child’s gear to an ice
rink at 5 a.m. for a 5:30 practice? Only a hockey
dad understands the “joys” of an unheated
arena, stamping a booted foot to keep warm, while
cheering on a son or daughter. Ice hockey is an often
misunderstood sport, known better for its violence,
especially fighting, than for the artistry on skates
and the demanding physical skills that the sport both
stresses and develops.
Yet I have an additional burden, for I am the goalie’s
father. My third son, Peter, is the only goal tender
for his bantam team. If the puck goes into the net,
my son has failed in his quest to keep the other team
from scoring. It matters not that the rest of the
team may have missed the puck or the defense man fell
or failed to clear a rebound — it all rests
at the end of the day on my son’s shoulders.
He revels in the pressure. But in a recent tournament,
with the possibility of playing in the championship
game on the line, Peter was beaten by an excellent
shot. The overtime loss, 1-0, was devastating. Peter
had stopped 28 previous shots to keep his team in
the game, and despite the encouragement and praise
of his teammates and coaches, he was emotionally crushed.
His friend, the girls’ varsity goalie at their
high school, waited for him to come out of the locker
room, for she alone understood the depths to which
his spirits had descended, and gave him a clue as
to how to get up for the third-place game that afternoon
— it was critical for the team to hold their
heads up high. Peter had to be at his best, for it
was going to be another hard-fought game against a
worthy opponent.
While sitting in the stands, I mused about how anesthesiology
is like ice hockey and most often resembles the goalie
position. We have many moments where quick action
is necessary. We make instant decisions about who
is ready for the operating room, often based upon
both the science of medicine and our intuition, which
in some ways is similar to the way a goalie “predicts”
where the puck will be shot. We try to be the wall
for our teammate, the patient, making sure that all
goes well. When we fail, it is obvious to all around,
even though there may have been little we could personally
do to prevent the tragedy.
“Is
it possible that one day, in the not-so-distant future,
the medical staff will simply be renamed ‘The
Staff,’ with no designation as to the responsibilities
for patient care and leadership within the health
care organization?”
The house of medicine, and anesthesiology, is facing
a new sharp shooter from the Joint Commission on Accreditation
of Healthcare Organizations. In a proposed hospital
accreditation standard, all physician assistants and
advanced-practice nurses will be required to be credentialed
and privileged through the medical staff process. While
this seems to be a minor chip on the ice surface, it
can have interesting implications. Licensed independent
practitioners (LIPs) are certified to work in the medical
center in this manner. Thus this may be a way for advanced-practice
nurses to further argue that they are the equivalents
to physicians. The alternative to this process is a
scope of practice whereby the advanced-practice nurse
duties and responsibilities are carefully delineated,
and there is often a statement about the circumstances
under which the practice occurs. Why bother with this
proposed standard?
LIPs are the key to the question. While the medical
staff of any given institution is free to choose whom
they credential and privilege or allow to work under
a scope-of-practice agreement, all LIPs need to be privileged
and credentialed. If this proposed standard goes forward,
the advanced-practice nurses have taken another step
toward equality with physicians. Simply put, physicians
will lose yet another, albeit minor, mechanism to direct
the practice of medicine. Is it possible that one day,
in the not-so-distant future, the medical staff will
simply be renamed “The Staff,” with no designation
as to the responsibilities for patient care and leadership
within the health care organization? Is it possible
for a nurse, most likely an advanced-practice one, to
lead “The Staff”?
Most interestingly, this issue was brought forward with
a front-page article in the AANA NewsBulletin
authored by Leo Le Bel, CRNA, J.D., M.Ed., who carries
the title of “Professional Practice Affairs Specialist.”1
Mr. Le Bel was not enthusiastic about this proposed
change, although he noted that in a recent survey of
nurse anesthetist practice, 70 percent of nurse anesthetists
were credentialed and privileged by the medical staff
process. His concern was that in switching from a scope-of-practice
to a credentialing process, nurse anesthetist practice
might be restricted. For example a nurse anesthetist
might be limited to general anesthesia if the medical
staff privileges were to restrict regional anesthesia
to physicians only.
Beyond the nurse anesthetist issue, there are greater
concerns for the specialty and the house of medicine.
Will advanced-practice nurses in gastroenterology be
credentialed and privileged to give deep sedation? Will
there be a new category of practitioner, neither anesthesiologist
nor nurse anesthetist, who is credentialed as a “sedation”
nurse to administer deep sedation throughout the hospital?
Anesthesiologists struggle with the twin competing “facts”
that there are not enough trained anesthesia professionals
to administer the appropriate care for all procedures
needing sedation and that deep sedation is fraught with
difficulties and may quickly trespass to general anesthesia
and death because of an individual who does not recognize
the depth of sedation produced or have the necessary
skill to manage the situation. It is a dilemma that
has led to a multitude of providers being “blessed”
as being adequate for moderate sedation and has led
third-party payers to unilaterally decide that anesthesiologists
are not necessary for sedation in most gastroenterology
procedures.
Is the future of patient care to be one in which physicians
have become superfluous? If the advanced-practice nurse
becomes truly independent, it will become possible for
patients to be cared for in the hospital setting without
ever being examined by a physician. There is no doubt
that insurance carriers, including our beloved federal
government, would find this system financially advantageous.
If the trend continues, will it be possible for a nurse
practitioner to do a colonoscopy — after all,
it is “just” a routine screening procedure?
Will “simple” appendectomies be done by
the advanced-practice nurse, with the anesthetic administered
by a sedation nurse, if the promise of transgastric
surgery comes to fruition? Is this the brave new future
we envision for medicine — or do we need to take
action now to ensure that patients receive the best
possible care?
What makes this scenario possible is that after a few
years of being treated like a LIP, advanced-practice
nurses will feel that they have become LIPs.
A political trip to the nursing board, followed by a
campaign in the legislature, can overturn long-standing
rules about the practice of medicine. A legislative
reformer likes nothing better than demonstrating how
the laws are antiquated and should be replaced. We have
seen this strategy employed in many states by the state
nurse anesthetists organizations. If the national nursing
organization got behind the changes, the change to LIP
status and becoming the equal of physicians might just
be impossible to stop — for there are many more
nurses than there are physicians.
In a tournament or playoff game at my son’s level
of hockey, when there is a tied score at the end of
regulation, there is a shootout after an overtime period
to determine a winner. The one-on-one confrontation
between the shooter and goalie is ice hockey in its
purest form. As the skater approaches the puck at full
speed, the goalie moves out of the net and begins to
challenge the shooter and perhaps cut off part of the
net, making scoring more difficult. There is nothing
more thrilling than save after save, watching the tension
mount, as each shooter tries to figure out the goal
tender faster than the opponent figures out his teammate.
We are faced with a similar situation. On this issue,
the house of medicine needs to determine two things:
First, are we the medical staff, or simply “The
Staff”? If we are the medical staff, then we need
to act like it. It’s time to block this most recent
shot — as the tension escalates in the advanced
practice nurse/physician contest.
— D.R.B.
Reference:
1. Le Bel L. JCAHO may require CRNA medical staff
credentialing. AANA NewsBulletin. 2006; 60(11):1,
5.
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