Kraig S. de Lanzac, MD, FASA
ASA Assistant Secretary
Imagine your family member is scheduled for elective surgery. One of the first things you would probably do, as an anesthesiology resident, is find out about the anesthesia care at that facility. You would get more information and possibly request the specific physician anesthesiologist that you want to care for your family member. You would do this because you know and understand the importance of safe anesthesia and all of the medical care that goes into preoperative preparation, evaluation and perioperative care. If you would do this for your own family, wouldn’t you want this to be done for all patients? But what if there were no physician anesthesiologists available at that facility or if the nurse anesthetists were delivering anesthesia care without a physician anesthesiologist’s supervision, or possibly no physician involvement at all? That is what is being proposed for our nations Veterans in the Veterans Administration (VA) Hospital system. Your actions today through SafeVACare.org
can stop this dangerous change in the care of our nation’s Veterans.
In April, VA’s Executive in Charge, Richard Stone, M.D., a dermatologist, issued a memo encouraging VA medical facilities to change their hospital bylaws to allow for provision of nurse-only anesthesia care. This was in response to the COVID pandemic, but we felt this was an unnecessary and dangerous move as the number of anesthetics being provided in the VA system, like most of our other systems, were very low. As you know, help was needed in the intensive care units. Now, on the day after Veterans Day, in an Interim Final Rule, the VA has once again set the stage to remove physician-led anesthesia care. This rule is open for public comment for 60 days, which began on November 12. The combination of the “Stone memo” and this new rule represent a threat to high quality, safe anesthesia care for Veterans.
The two questions I get asked most often about this issue are, “Can we do anything about this?” and, “Haven’t we done this before?” The answer to both questions is yes. In 2017, after a nearly four-year effort to stop a VA proposal which would remove physician supervision of nurse anesthetists, the VA issued a final rule which preserved physician-led anesthesia care of our nation's Veterans. Were it not for the grassroots groundswell of opposition to the initial proposal, Veterans would have lost the benefit of physician-led anesthesia care that they enjoy today. Over 100,000 comments supported preserving physician-led anesthesia care. Unfortunately, now that victory for Veterans is jeopardized. Despite the previously expressed overwhelming opposition by physicians, Veterans, Veterans’ organizations, and the general public, the new proposal threatens once again to remove physicians from the anesthesia care of Veterans.
We can stop this as we did before. We need every physician anesthesiologist including every resident anesthesiologist to defend physician-led care of our Veterans. This can be easily done within a few minutes by going to SafeVACare.org and expressing your support of the current requirement for physician supervision of nurse anesthetists in the VA system. We are also invoking our successful “1 + 5” strategy, which requests that not only do you submit a comment, but you encourage and direct 5 others to comment as well. Anyone can participate and it is very easy. Residents are always asking me how they can get involved and make a difference. This is an easy task that you can take on and make a positive impact on the care of our nation’s Veterans. Don’t stop at five. Get your entire department and your circle of family and friends to engage and protect our Veterans. If you don't speak up for Veterans regarding your specialty, who will? Don't count on others to do it for you. We need every ASA member and as many members of the public that we can educate to oppose this dangerous change in the VA system.
The issue of physician supervision and related terminology can be very confusing, so allow me to provide a little background information. When it comes to personnel, there are several ways that anesthesia care can be delivered. In some areas, anesthesia is delivered by a solo physician anesthesiologist, much like you are currently doing as residents. In this model, care is completely provided by an anesthesiologist. Most commonly, anesthesia care is delivered utilizing the anesthesia care team led by a physician anesthesiologist supervising nurse anesthetists and anesthesiologist assistants. In some cases, nurse anesthetists deliver anesthesia under the supervision of the operating physician (like the surgeon, ophthalmologist, or gastroenterologist) without a physician anesthesiologist.
Supervision is a term frequently used/defined in statute or regulation, which conveys that a physician is responsible and oversees care delivered by a non-physician anesthetist. The vast majority of states require physician involvement, oversight, or supervision of nurse anesthetists, which can be any physician, including the operating physician. Ideally, a physician anesthesiologist-led team delivers anesthetic care for patients. There are two billing terms also commonly used to describe the involvement of the physician anesthesiologist. These terms are Medical Direction and Medical Supervision. Both of these constitute physician supervision, but they are different. In a Medical Direction model, physician anesthesiologists must direct no more than four anesthetic locations and must meet several well-described elements of care. In Medical Supervision, more anesthetic locations are allowed to be supervised and the level of care and involvement of the physician anesthesiologist may be less. Please remember that these are billing terms and not care terms.
When nurse anesthetists and other nurse practitioners attempt to remove physician supervision, it means all physician supervision/involvement. They seek to authorize a practice design where the physician anesthesiologist is not a part of the patients’ care and even the operative physician is not required to oversee or be responsible for their own patients’ anesthetic care. The problem is that all patients presenting to surgery bring with them medical conditions that can affect their perioperative care. I always like to compare this to patients bringing baggage to their anesthetic. Even if the procedure is minor, some patients bring an overnight bag’s worth of medical problems while others require a trunk to carry all of their coexisting conditions that must be managed and optimized before during and after an anesthetic. This care is best delivered and supervised by a physician, ideally a physician anesthesiologist.
ASA believes that all patients should have access to physician-led anesthesia care, ideally under a physician anesthesiologist, but always under a physician. We believe patients deserve this standard of care. Your actions today can make a difference in the care of our nation’s Veterans. Please go to SafeVACare.org and let the VA know that Veterans deserve safe, high-quality, physician-led anesthesia care. Encourage others to do so as well. This is your specialty, and these are your patients. Please speak up for them now.