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Ryan Gamlin, M.S. University of Cincinnati College of Medicine
As ambassadors of anesthesiology within our medical schools, it is important for members of the ASA- MSC to understand both the current landscape of anesthesia care and to stay informed as to legislative changes affecting the specialty.
Many fields of medicine use midlevel providers (MLP) – a phrase generally used to refer to advanced practice registered nurses (APRNs) and physician assistants (PAs) – and most students interested in anesthesiology are familiar with at least one type of MLP: the certified registered nurse anesthetist (CRNA). While CRNA practice can be a divisive issue, with more than 100 million surgeries performed annually in the United States, there are simply not enough physician anesthesiologists to provide all of the anesthesia care required by a growing and aging population.
MLPs are, therefore, crucial elements within the health care delivery system, in both operative and non-operative settings. Of the approximately 205,000 APRN’s in the U.S., 48,000 are CRNAs (with the majority of the remainder licensed as nurse practitioners and certified nurse midwives). Physician assistants, a role much more recently defined than nursing, total approximately 92,000, with 1,500 of those practicing as a specialized form of PA, the anesthesiologist assistant (AA).
Both types of MLP providing anesthesia have received specialized training, and both are used to effectively extend the physician anesthesiologist’s ability to provide high-quality patient care. The American Society of Anesthesiologists® (ASA®) supports CRNA- and AA-provided anesthesia within the Anesthesia Care Team (ACT) model:
Directed by an anesthesiologist, the Anesthesia Care Team consists of anesthesiologists supervising qualified nonphysician anesthesia providers and/or resident physicians who are training in the provision of anesthesia care. The anesthesiologist may delegate patient monitoring and appropriate tasks to these nonphysician providers while retaining overall responsibility for the patient.
One crucial difference between CRNAs and AAs is their scope of “independent” practice: all physician assistants (including anesthesiologist assistants) must be supervised by a physician, while laws regulating APRNs’ authority for independent practice vary state-to-state. According to the National Council of the State Boards of Nursing, 24 states and the District of Columbia allow CRNAs to provide anesthesia independent of physician collaboration or oversight.
The latest threat to physician-led anesthesia, however, has come not at the state level, but within the Veterans Health Administration (VHA), the nation’s largest integrated health care system. Currently, APRNs who work in VHA facilities are subject to the laws of the state in which they are licensed. House Resolution (H.R) 1247, introduced in March 2015, would allow APRNs who work in VHA facilities “full practice authority,” removing the need for physician oversight of CRNAs.
As student members of the ASA, we are the next generation of advocates for high and unwavering standards of patient medical care. Educate yourself about the issues – federal, state and local – facing anesthesiology specifically and the practice of medicine broadly. The ASA website’s “Advocacy” section (https://www.asahq.org/advocacy ) has a number of resources for peer and patient education. Organized opportunities to have your voice heard, such as the recent Legislative Conference in Washington, D.C., provide a forum to work directly with others deeply involved in these debates so critical to patient safety and the future of the specialty.
Anesthesiology is an incredible field, with leaders in basic science, clinical research, patient safety and health administration. I suspect that as student members of the AMA-MSC, most of us identify at least one of our professional aspirations within that list. Equally important, however, is the health of the specialty as a whole, and it is our collective responsibility to ensure it withstands the continually changing political landscape. I urge you to take the time to gain an understanding of the challenges facing anesthesiology and to become involved in whatever capacity best utilizes your unique talents and ambitions.
