What's In This for the Patient?
Good afternoon Chairman McGeehan and members of the House Professional Licensure Committee. I am James Goodyear, MD, president of the Pennsylvania Medical Society. As you may already know, our organization is the largest statewide physician organization with approximately 20,000 members.
To better understand and appreciate my comments to you this morning it may be helpful for you to know that I am a board certified general surgeon, and I have been in practice here in Pennsylvania for nearly 30 years. I practice in Montgomery County.
Let me begin by saying that I sincerely appreciate the opportunity, as a surgeon, to share my thoughts with you about House Bill 1866. I would also like you to know from the outset that nurse anesthetists play a critical role on many surgical teams. I use the word team with the utmost respect for all of the individuals who work with me in the operating room including nurses, circulating technicians, scrub technicians, surgical assistants, nurse anesthetists and lastly, physician anesthesiologists. I also use the word team for another purpose…every member of the surgical team is critical to the overall health and safety of the patient. While you will all agree that there is no “I” in team, every team needs a leader and every team member has a specific function.
As the “leader” of my surgical team, I rely on each and every team member. Today, we are specifically addressing the responsibilities, functions, and duties of a frequent member of that team…the nurse anesthetist. I am the first to admit that nurse anesthetists are at times, invaluable in the OR. But I have serious concerns about how their “position” on my team will change if House Bill 1866 is enacted, which is why we oppose this measure.
Obviously, the education and training of any professional, be it a lawyer, architect, or pilot, clearly dictates their authority to perform a particular function. Paralegals are not permitted to practice law, draftsmen cannot certify that a particular beam is structurally sound, and I don’t think any of us would want a recreational pilot at the controls of a 747.
Nurse anesthetists are incredibly talented individuals. But they do have limitations. I too have limitations. As a physician I hold an “unlimited license” to practice medicine. As I mentioned earlier I am a general surgeon. I cannot perform ocular surgery, neurosurgery, or cardiothoracic surgery. I was educated and trained to perform abdominal surgery. Again, I have clinical limitations.
Nurse anesthetists are no different. While they effectively administer anesthesia and skillfully monitor an anesthetized patient, to assure safety and quality of patient care, they require supervision by a physician…ideally by an anesthesiologist. The current structure of “supervised anesthesia care by a nurse anesthetist” works. In fact, it works well. Ironically, when I first learned that this committee was holding a hearing on this issue, my first thought was not to advocate for a relaxation of current regulations but rather a strengthening of the current “supervision” procedures to include a clearly defined and written protocol between the nurse anesthetist and the physician supervisor; a “collaborative agreement” which specifically defines the duties and privileges of the nurse anesthetist. That is something that I encourage this committee to strongly consider in lieu of the language currently found in House Bill 1866.
The administering of anesthesia is serious business. In fact, injecting potentially lethal drugs into a patient that not only induces sleep but also paralyzes them should not be taken lightly. Clinical medicine today is so sophisticated and our anesthetizing drugs are so effective that both patients and their families have a false sense of security when it comes to surgery. I have to laugh sometimes when a family member accompanies a loved one to the hospital for an out-patient hernia procedure and asks if they can run some errands while Uncle Joe is being operated on. Knowing the inherent risks of any surgical procedure, I encourage them to not leave the hospital.
Please know that my goal today is not to scare you into thinking that undergoing surgery, even for a minor procedure, is like rolling the dice at the craps table. Physicians and surgeons have worked diligently in making surgical care in the OR quite safe. But I do want you to leave this hearing room today knowing that bad things can happen during surgery that are completely out of everyone’s control. And when things go wrong, and believe me an otherwise healthy patient can crash in seconds, you want the experienced pilot who has flown that 747 for 20 years, not the weekend aviator. Again, nurse anesthetists are highly skilled but have limitations.
Let’s put aside, for the moment, the issue of physician supervision of nurse anesthetists and consider what this bill will do and won’t do. In my opinion the changes proposed in this bill will create a degree of uncertainty in my operating room and may potentially lead to incidents that I would otherwise not encounter under our current work flow. While I do not wish to paint for you a picture whereby patient mortality will significantly increase if House Bill 1866 were to be enacted, I can assure you that incidents will occur that will put patients in serious jeopardy because an anesthesiologist wasn’t immediately available. If only one patient encounters a “close call” or god forbid something worse as a result of this proposed change, that is one patient too many.
Over the years claims of cost reductions by non-physician health care providers have been misleading. With respect to anesthesia care, reimbursement is typically considered a “global fee” and is not adjusted based on who administered the drugs or supervised the care. Ultimately, the fee is split between the anesthesia care providers or supervising surgeon. Interestingly, if this legislation were to be enacted, costs would likely increase since nurse anesthetists are not trained to diagnosis and prescribe an operative protocol thereby often requiring a separate consultation with an anesthesiologist to determine what cocktail of drugs to use based on the patient’s medical history and the procedure being performed.
The last issue I would like to briefly touch upon is the recurring question of access to anesthesia care that is all too often raised in this arena. From time to time we hear non-physician providers claim that they can “provide care to patients where physicians are unwilling to practice.” This is simply not true. Are there areas of the state that do not have the luxury of having an anesthesiologist on site. You bet there are. But those same areas do not have nurse anesthetists either. (It’s like the famous bank robber Willy Sutton once said when asked why he robs banks, “because that’s where the money is.” The same analogy holds true for those delivering health care service, we largely practice where the patients are…in the same large urban or suburban area.)
In an effort to more effectively address the issue of access to anesthesia care here in Pennsylvania, I have attached two exhibits that speak to the distribution of both physician and non-physician anesthesia providers in the Commonwealth. The data source for these charts was the Pennsylvania Bureau of Professional and Occupational Affairs, the American Medical Association, and the American Osteopathic Association. I believe you will find them very helpful.
Suffice it to say today’s operating rooms are functioning without incident as it relates to anesthesia care. I cannot imagine that any of your constituents have contacted you because of their inability to secure quality anesthesia care. There is a reason your phone isn’t ringing with those concerns.
Again Mr. Chairman, thank you for the opportunity to share with you the Pennsylvania Medical Society’s concerns about this legislation. To the best of my ability, I would be happy to take any questions you may have regarding my remarks here today.
Last Updated: 1/26/2010