With all this recent talk about the AANA/CRNAs, I felt compelled to join and post this excellent article from a prior ASA Newsletter. Please take a few minutes to read the entire article below.
P.S. There was a "top 10 list of things we can do to stop the AANA" that someone posted here a while back... can someone help me find that post?
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The question of scope of practice did not begin with the Centers for Medicare & Medicaid Services (CMS) final rule allowing for opt-out in 2001. It smoldered among anesthesiologists and nurse anesthetists for decades. Recently, the push for expanded scope of practice has raised the temperature of the debate, and with the publication of Dulisse and Cromwells article in Health Affairs (No Harm Found When Nurse Anesthetists Work Without Supervision by Physicians. Health Affairs. 2010; 29[8]:1-7), it got a lot hotter. Then a New York Times September 6 editorial asked, Can a highly trained nurse deliver anesthetics as well as a physician who has specialized in anesthesiology, or does the nurse require close medical supervision? and ended with anesthesiologists earn twice as much a year, on average, as the nurses do, with no discussion as to why this earning difference exists (e.g., hours worked). This editorial further increased the heat of the scope-of-practice issue.
Its not such a bad editorial if you think of it as satire. Unfortunately, it is not. The inherent contradictions are ironic and informative, such as, There is not much difference between the two professions [anesthesiologists and anesthesia nurses], the amount of training they get, juxtaposed with, Where the anesthesiologists have a big advantage is in their much longer and broader medical training that, many doctors say, may better equip them to handle complex cases and the rare emergencies that can develop from anesthesia. Many of those doctors are surgeons who get very nervous when they dont have a familiar anesthesiologist around to manage things when the ideal world of the routine gets interrupted.
The editorial then goes on to compare relative annual rather than hourly incomes, sidestepping the equivalence of Medicare payments, nights and weekends on call, and other elements of perioperative care. Ironically, the editorials final line is left open to interpretation. Here, the real argument about cost slips out accidentally: As health reformers seek ways to curb medical spending, they need to consider whether this is a safe place to do it. That old Clint Eastwood line pops into mind every time I hear about cheaper, less-educated nurses giving anesthesia solo: Are you feeling lucky ...? Its all about the odds. Patients need to know the odds.
The heat generated from this and similar editorials in the month preceding our annual meeting underscores the need for a broader, more organized and proactive advocacy by ASA. While health care reform, a.k.a., Patient Protection and Affordable Care Act (PPACA), alone justifies the need for a heavy metal approach to advocacy, scope of practice remains one of the most frustrating areas of the battle for logic and intelligent debate.
So, lets take a look at some of the specifics. Some contend that anesthesia is so intrinsically safe that so-called low-risk procedures in healthy patients do not require a physician to supervise the anesthesia care. That conclusion is not only spurious, but is not ethically testable.
With Orwellian logic, we are being told we need hard data to prove we cant be imprudent. Forget for the moment that the proof in the Health Affairs article is fatally fl awed and any randomized controlled study would be unethical. Lack of data to prove nurses dont need supervision does not prove they do not need supervision (triple negative intended). In logic, this is called the argument from ignorance, an informal logical fallacy. It asserts that a proposition is necessarily true because it has not been proven false (or vice versa). For example, there is no proof that UFOs are not visiting earth, therefore they are.
In sum, the lack of proof is just that. A randomized controlled trial (RTC) with anesthesiologists and nurses taking care of equivalent populations (same morbidities, procedures, complexities, etc.) without access to each other (i.e., no possibility of rescue) will never be done any more than we would do an RCT to determine the value of oximetry. No IRB would approve the protocol or the consent. In the end, the insurance actuaries will give us the true answer about unsupervised anesthesia, should it actually ever occur in pure form. Actuaries care not a whit for RCTs, arguments and propaganda. All they do is look coldly at the history of loss. Meanwhile, without a crystal ball to guide us, we must attend all procedures with the same high level of care and the same expertise provided by physician supervision or risk unnecessary morbidity and deaths.
In a recent Bloomberg Business article, Ryanairs CEO asked why we need even a co-pilot on planes when they can be flown safely by the computer. He says that in an emergency, if the pilot were incapacitated, the fight attendant could land the plane if trained to do so. Flying and anesthesia are safe because highly trained professionals are there when things do not go exactly as planned. Computers backed up by flight attendants are unlikely to land a flamed out plane in the Hudson. Who would agree in advance to fly with a lesser-trained crew? Who would be willing to have a tattoo saying I want no physician involved in my anesthetic. How many of our opt-out governors, legislators or CMS policy-makers want that tattoo?
A couple of weeks after ANESTHESIOLOGY 2010, with Jeff Skiles wonderful presentation about what it takes to land a plane in the Hudson still resonating in my mind, I went back to San Diego to speak to the AMA Scope of Practice Partnership. It took place in the same Marriott I had stayed in two weeks previously. As I looked over the standing room-only crowd, I reflected that the attention being paid to scope of practice was both exhilarating and frightening. It was clear that all of the ironies, concerns and fears for patient safety that seemed to be bottled up like a genie in anesthesiology were now out of the bottle and spreading throughout all of medicine. We had been sending the message out like a Search for Extra-Terrestrial Intelligence project, and after so long, we find that we are not alone, and there is other intelligent life out there, in a corner of the AMA, that gets it. As PPACA rolls out, other physicians are becoming concerned about the blurring of the boundaries between medicine and nursing and what it means to safety and cost.
There are several truths that seem obvious to us that we must communicate better. Parts of PPAC are good and we need them, but when we are asked to suspend critical thinking and ignore simple inconvenient facts, the solutions become fantastic. So we must drive home the big picture. The practice of medicine is not the practice of nursing. Medical education is unique and has different aims than nursing education. A premedical education has different aims and a different curriculum than a pre-nursing education. Medical management is different than nursing management and has entirely different objectives. Technical skill is not the same as judgment, even when nurses and doctors share techniques. The consequence is that carrying out a plan when things are going well is not the same as making the plan when unexpected and uncommon events occur. This underlies the estimate that the presence of an anesthesiologist prevents six excess deaths per thousand anesthetized patients.
Several misconceptions underlying opt out need to be driven home. The idea that nurses will move to rural areas if their governors opt out of supervision is not supported by data reflecting substantial migration into those areas, even with the relative advantages of payment not accorded anesthesiologists.
Nurses have taken the use of the QZ payment modifier in optout states and inappropriately reported it as a surrogate for solo practice. The lack of payment for medical direction is in no way an indicator of lack of overall physician supervision. Thus, the basic premise of the Dulisse and Cromwell paper is invalid. Further, the legal liabilities of the surgeon or proceduralist physician are not changed by a change in payment rules.
Undeterred by reason and supported by boards of nursing, nurses argue that pain medicine is a practice of nursing. The Alabama State Board of Medical Examiners recently defined pain medicine as the practice of medicine. The Federal Trade Commission (FTC), paraphrasing other opinions issued by the Obama Administration and his regulatory agencies, cautioned that limiting the practice of pain medicine to physicians might limit access to care and be a restraint of trade on nurses who practice within the scope of care established by the Alabama Board of Nursing. The notion that limiting scope of practice is a form of unlawful discrimination is another piece of illogic that has become part of the mix. The resulting shell game with logic threatens the basic rights of states to regulate health care safety and would cede to nursing boards the exclusive right to define nursing scope of practice, unencumbered by the obvious conflicts of interest.
The FTC is correct that there are economic benefits to being paid for a service. This is why some nurses want to practice medicine without going to medical school. It is a quicker and less expensive path. The best way to learn how to competently practice medicine is to go to medical school, not the legislature or the courts. Legal shortcuts do not make a nurse a physician.If the FTC usurps the rights of the states to determine who delivers medical care, what else can we expect in the way of federal intrusions as health care reform rolls over issues of safety in pursuit of the illusion of a bargain?
Recently, ASA mobilized aggressive support to help the Colorado Society of Anesthesiologists oppose an opt-out. Although not completely successful, our collective efforts did limit the hospitals to which the opt-out applied. The society was more successful in Iowa, where the Iowa Board of Nursing approved a rule allowing advanced registered nurse practitioners (including nurse anesthetists) to use fluoroscopy. The Iowa Society of Anesthesiologists (ISA) saw this as a rule that would allow nurses to expand their scope of practice to perform intervention pain medicine. It therefore sought a state law to preempt the nursing board ruling. When this tack failed, the Iowa Board of Health implemented the Board of Nursings rule. The ISA and the Iowa Medical Society promptly filed litigation against the Board of Nursing to prevent implementing its rule. In November, implementation was stopped by court order pending a final hearing. It appeared to the judge of jurisdiction that the ISA filing would have a high probability of success. She said her court order was justified because the Board of Nursing had overstepped the boundaries established by statute in an attempt to override legislative directives set forth in existing law. This outcome was aided by the numerous agencies submitting written objections, including the Iowa Board of Medicine, various radiologists and their organizations, the American College of Surgeons and the AMA.
There have been other advocacy successes. Last April in Oklahoma, the state legislature passed the Interventional Pain Management and Treatment Act, which limits the practice of pain medicine to physicians. This past year, the Arizona Society of Anesthesiologists succeeded in getting the Arizona Board of Nursing to review its decision to allow nurse anesthetists to prescribe medications to treat chronic pain. And over a two-year period, Louisiana defined pain medicine as the practice of medicine.
We must constantly oppose the magical thinking that extenders can do the same thing as physicians at a lower cost. Cost-effective integration of health care requires the use of teams. Teams require members to have specific abilities. They are not interchangeable. They are organic; not one of them can function effectively without the others. However, we must reinforce the idea that care teams work because physicians supervise them.
Lessons learned from these distinctly different efforts make it clear that being reactive and trying to respond to the problem of the week is expensive and not as effective as having the capacity to address the many issues of health policy in an ongoing proactive way. While anesthesiologists are at the point of arguments to put safety first in scope-of-practice decisions, it affects all of medicine. We need to work both with other specialties and on our own to establish safe, effective, economical health care policy. We need to support these efforts at the level of our state components as well as on a national level. To review our current health policy expertise and resources, we have appointed an Ad Hoc Committee on Healthcare Policy. It is led by Arthur Boudreaux, M.D. The members of this committee will assess how we can appropriately marshal our assets to make us effective in molding health care policy. A review of our existing resources and the approaches used by others will be a valuable first step. Operationalizing this critical effort will be the key challenge, as will defining and measuring its success. By the time this article is published, the committee should have met and recommended a road map for our efforts.
When it comes to health care and scope of practice, there are truths that seem in danger of being ignored at the risk of replicating the tragedy observed by the famous philosophers Simon and Garfunkel. Policy can be all lies and jests when a man hears what he wants to hear and disregards the rest This is how America is put at risk of squandering the safety of physician care for a pocketful of mumbles, such are [the] promises of the illusion of uncompromised safety at bluelight special prices. Our job is to be effective advocates for the safety our patients and policies that promote the best care possible. In the end, this is true economy.
P.S. There was a "top 10 list of things we can do to stop the AANA" that someone posted here a while back... can someone help me find that post?
................................................................................................................................................................................
The question of scope of practice did not begin with the Centers for Medicare & Medicaid Services (CMS) final rule allowing for opt-out in 2001. It smoldered among anesthesiologists and nurse anesthetists for decades. Recently, the push for expanded scope of practice has raised the temperature of the debate, and with the publication of Dulisse and Cromwells article in Health Affairs (No Harm Found When Nurse Anesthetists Work Without Supervision by Physicians. Health Affairs. 2010; 29[8]:1-7), it got a lot hotter. Then a New York Times September 6 editorial asked, Can a highly trained nurse deliver anesthetics as well as a physician who has specialized in anesthesiology, or does the nurse require close medical supervision? and ended with anesthesiologists earn twice as much a year, on average, as the nurses do, with no discussion as to why this earning difference exists (e.g., hours worked). This editorial further increased the heat of the scope-of-practice issue.
Its not such a bad editorial if you think of it as satire. Unfortunately, it is not. The inherent contradictions are ironic and informative, such as, There is not much difference between the two professions [anesthesiologists and anesthesia nurses], the amount of training they get, juxtaposed with, Where the anesthesiologists have a big advantage is in their much longer and broader medical training that, many doctors say, may better equip them to handle complex cases and the rare emergencies that can develop from anesthesia. Many of those doctors are surgeons who get very nervous when they dont have a familiar anesthesiologist around to manage things when the ideal world of the routine gets interrupted.
The editorial then goes on to compare relative annual rather than hourly incomes, sidestepping the equivalence of Medicare payments, nights and weekends on call, and other elements of perioperative care. Ironically, the editorials final line is left open to interpretation. Here, the real argument about cost slips out accidentally: As health reformers seek ways to curb medical spending, they need to consider whether this is a safe place to do it. That old Clint Eastwood line pops into mind every time I hear about cheaper, less-educated nurses giving anesthesia solo: Are you feeling lucky ...? Its all about the odds. Patients need to know the odds.
The heat generated from this and similar editorials in the month preceding our annual meeting underscores the need for a broader, more organized and proactive advocacy by ASA. While health care reform, a.k.a., Patient Protection and Affordable Care Act (PPACA), alone justifies the need for a heavy metal approach to advocacy, scope of practice remains one of the most frustrating areas of the battle for logic and intelligent debate.
So, lets take a look at some of the specifics. Some contend that anesthesia is so intrinsically safe that so-called low-risk procedures in healthy patients do not require a physician to supervise the anesthesia care. That conclusion is not only spurious, but is not ethically testable.
With Orwellian logic, we are being told we need hard data to prove we cant be imprudent. Forget for the moment that the proof in the Health Affairs article is fatally fl awed and any randomized controlled study would be unethical. Lack of data to prove nurses dont need supervision does not prove they do not need supervision (triple negative intended). In logic, this is called the argument from ignorance, an informal logical fallacy. It asserts that a proposition is necessarily true because it has not been proven false (or vice versa). For example, there is no proof that UFOs are not visiting earth, therefore they are.
In sum, the lack of proof is just that. A randomized controlled trial (RTC) with anesthesiologists and nurses taking care of equivalent populations (same morbidities, procedures, complexities, etc.) without access to each other (i.e., no possibility of rescue) will never be done any more than we would do an RCT to determine the value of oximetry. No IRB would approve the protocol or the consent. In the end, the insurance actuaries will give us the true answer about unsupervised anesthesia, should it actually ever occur in pure form. Actuaries care not a whit for RCTs, arguments and propaganda. All they do is look coldly at the history of loss. Meanwhile, without a crystal ball to guide us, we must attend all procedures with the same high level of care and the same expertise provided by physician supervision or risk unnecessary morbidity and deaths.
In a recent Bloomberg Business article, Ryanairs CEO asked why we need even a co-pilot on planes when they can be flown safely by the computer. He says that in an emergency, if the pilot were incapacitated, the fight attendant could land the plane if trained to do so. Flying and anesthesia are safe because highly trained professionals are there when things do not go exactly as planned. Computers backed up by flight attendants are unlikely to land a flamed out plane in the Hudson. Who would agree in advance to fly with a lesser-trained crew? Who would be willing to have a tattoo saying I want no physician involved in my anesthetic. How many of our opt-out governors, legislators or CMS policy-makers want that tattoo?
A couple of weeks after ANESTHESIOLOGY 2010, with Jeff Skiles wonderful presentation about what it takes to land a plane in the Hudson still resonating in my mind, I went back to San Diego to speak to the AMA Scope of Practice Partnership. It took place in the same Marriott I had stayed in two weeks previously. As I looked over the standing room-only crowd, I reflected that the attention being paid to scope of practice was both exhilarating and frightening. It was clear that all of the ironies, concerns and fears for patient safety that seemed to be bottled up like a genie in anesthesiology were now out of the bottle and spreading throughout all of medicine. We had been sending the message out like a Search for Extra-Terrestrial Intelligence project, and after so long, we find that we are not alone, and there is other intelligent life out there, in a corner of the AMA, that gets it. As PPACA rolls out, other physicians are becoming concerned about the blurring of the boundaries between medicine and nursing and what it means to safety and cost.
There are several truths that seem obvious to us that we must communicate better. Parts of PPAC are good and we need them, but when we are asked to suspend critical thinking and ignore simple inconvenient facts, the solutions become fantastic. So we must drive home the big picture. The practice of medicine is not the practice of nursing. Medical education is unique and has different aims than nursing education. A premedical education has different aims and a different curriculum than a pre-nursing education. Medical management is different than nursing management and has entirely different objectives. Technical skill is not the same as judgment, even when nurses and doctors share techniques. The consequence is that carrying out a plan when things are going well is not the same as making the plan when unexpected and uncommon events occur. This underlies the estimate that the presence of an anesthesiologist prevents six excess deaths per thousand anesthetized patients.
Several misconceptions underlying opt out need to be driven home. The idea that nurses will move to rural areas if their governors opt out of supervision is not supported by data reflecting substantial migration into those areas, even with the relative advantages of payment not accorded anesthesiologists.
Nurses have taken the use of the QZ payment modifier in optout states and inappropriately reported it as a surrogate for solo practice. The lack of payment for medical direction is in no way an indicator of lack of overall physician supervision. Thus, the basic premise of the Dulisse and Cromwell paper is invalid. Further, the legal liabilities of the surgeon or proceduralist physician are not changed by a change in payment rules.
Undeterred by reason and supported by boards of nursing, nurses argue that pain medicine is a practice of nursing. The Alabama State Board of Medical Examiners recently defined pain medicine as the practice of medicine. The Federal Trade Commission (FTC), paraphrasing other opinions issued by the Obama Administration and his regulatory agencies, cautioned that limiting the practice of pain medicine to physicians might limit access to care and be a restraint of trade on nurses who practice within the scope of care established by the Alabama Board of Nursing. The notion that limiting scope of practice is a form of unlawful discrimination is another piece of illogic that has become part of the mix. The resulting shell game with logic threatens the basic rights of states to regulate health care safety and would cede to nursing boards the exclusive right to define nursing scope of practice, unencumbered by the obvious conflicts of interest.
The FTC is correct that there are economic benefits to being paid for a service. This is why some nurses want to practice medicine without going to medical school. It is a quicker and less expensive path. The best way to learn how to competently practice medicine is to go to medical school, not the legislature or the courts. Legal shortcuts do not make a nurse a physician.If the FTC usurps the rights of the states to determine who delivers medical care, what else can we expect in the way of federal intrusions as health care reform rolls over issues of safety in pursuit of the illusion of a bargain?
Recently, ASA mobilized aggressive support to help the Colorado Society of Anesthesiologists oppose an opt-out. Although not completely successful, our collective efforts did limit the hospitals to which the opt-out applied. The society was more successful in Iowa, where the Iowa Board of Nursing approved a rule allowing advanced registered nurse practitioners (including nurse anesthetists) to use fluoroscopy. The Iowa Society of Anesthesiologists (ISA) saw this as a rule that would allow nurses to expand their scope of practice to perform intervention pain medicine. It therefore sought a state law to preempt the nursing board ruling. When this tack failed, the Iowa Board of Health implemented the Board of Nursings rule. The ISA and the Iowa Medical Society promptly filed litigation against the Board of Nursing to prevent implementing its rule. In November, implementation was stopped by court order pending a final hearing. It appeared to the judge of jurisdiction that the ISA filing would have a high probability of success. She said her court order was justified because the Board of Nursing had overstepped the boundaries established by statute in an attempt to override legislative directives set forth in existing law. This outcome was aided by the numerous agencies submitting written objections, including the Iowa Board of Medicine, various radiologists and their organizations, the American College of Surgeons and the AMA.
There have been other advocacy successes. Last April in Oklahoma, the state legislature passed the Interventional Pain Management and Treatment Act, which limits the practice of pain medicine to physicians. This past year, the Arizona Society of Anesthesiologists succeeded in getting the Arizona Board of Nursing to review its decision to allow nurse anesthetists to prescribe medications to treat chronic pain. And over a two-year period, Louisiana defined pain medicine as the practice of medicine.
We must constantly oppose the magical thinking that extenders can do the same thing as physicians at a lower cost. Cost-effective integration of health care requires the use of teams. Teams require members to have specific abilities. They are not interchangeable. They are organic; not one of them can function effectively without the others. However, we must reinforce the idea that care teams work because physicians supervise them.
Lessons learned from these distinctly different efforts make it clear that being reactive and trying to respond to the problem of the week is expensive and not as effective as having the capacity to address the many issues of health policy in an ongoing proactive way. While anesthesiologists are at the point of arguments to put safety first in scope-of-practice decisions, it affects all of medicine. We need to work both with other specialties and on our own to establish safe, effective, economical health care policy. We need to support these efforts at the level of our state components as well as on a national level. To review our current health policy expertise and resources, we have appointed an Ad Hoc Committee on Healthcare Policy. It is led by Arthur Boudreaux, M.D. The members of this committee will assess how we can appropriately marshal our assets to make us effective in molding health care policy. A review of our existing resources and the approaches used by others will be a valuable first step. Operationalizing this critical effort will be the key challenge, as will defining and measuring its success. By the time this article is published, the committee should have met and recommended a road map for our efforts.
When it comes to health care and scope of practice, there are truths that seem in danger of being ignored at the risk of replicating the tragedy observed by the famous philosophers Simon and Garfunkel. Policy can be all lies and jests when a man hears what he wants to hear and disregards the rest This is how America is put at risk of squandering the safety of physician care for a pocketful of mumbles, such are [the] promises of the illusion of uncompromised safety at bluelight special prices. Our job is to be effective advocates for the safety our patients and policies that promote the best care possible. In the end, this is true economy.
