Sunday, October 3, 2021

Are Anesthesiologists Just Glorified Nurses?


In a provocative op-ed in Anesthesiology News (free membership required), Dr. Karen Sibert, past president of the California Society of Anesthesiologists, dared to ask if anesthesiologists are truly practicing like physicians, or merely doing nurses' work. Full disclosure: I know Dr. Sibert personally and have worked with her in the past.

She asks why are anesthesiologists responsible for drawing up drugs? Why are anesthesiologists the ones to hang medications on IV pumps? Why are anesthesiologists charting IV fluids and urine outputs? Do you ever see internists grab a syringe and check out drugs from a Pyxis to give to a patient? Of course not. They write an order and the pharmacist and nurse carries it out. Oncologists don't hang drugs themselves. They give orders to a nurse who then loads the IV pump to give to the patient. When a surgeon asks for preincision antibiotics, who does he give the orders to? That's right. It's the anesthesiologist who mixes it up and administers it to the patient. How did anesthesiologists' duties become so mundane and nursing oriented?

Dr. Sibert goes goes into a little bit of history of anesthesiology to explain the current conundrum. In the early 1900's, most surgeons would use a nurse to administer sedation in the operating room. The same nurse might then follow the surgeon to the office later in the day for office duties. There was no such thing as an anesthesiologist involved. Then along came Ralph Waters, MD. 

Dr. Waters was one of the pioneers of anesthesiology, a lion of the specialty. He treated anesthesiology as a true science, with rigorous research and observations. He began the first anesthesiology residency in the United States, at the University of Wisconsin, Madison in 1927. 

But unfortunately the practice of providing anesthesia had by then been strongly established as a nursing duty supervised by a surgeon. It took decades of work before anesthesiology was officially recognized as a physician specialty and fully independent of a surgeon's purview. 

Dr. Sibert noted the difference between the European model of giving anesthesia versus the American one. Europeans require two professionals present during critical phases of the case, either an anesthesiologist and an assistant or an anesthesiologist and a nurse. The US does not have this requirement so a CRNA can do the job all by themselves without any supervision of an anesthesiologists.

European anesthesiologists are also much more involved in the patient care throughout their hospitalization, not just in the operating room. Patients are evaluated by anesthesiologists preop. They are then followed through the operating room, possible ICU stay, postop recovery, pain management, and even after discharge. The anesthesiologists act as a hospitalist or internist for the patient. This is the aim of the Perioperative Surgical Home that was so in vogue a few years ago. But most American anesthesiologists would rather quit than to have to follow their patients that thoroughly. ("If I wanted to be a hospitalist, I would have gone into medicine and become a hospitalist!")

Those are the kinds of responsibilities that medical students and residents are trained to excel. We're experts at evaluating the big picture to determine whether a patient can safely undergo anesthesia and to take care of them perioperatively. Why do so many anesthesiologists not want to broaden the scope of their practice and are satisfied with drawing up syringes of propofol and just get through the day? 

Because it's easy, that's why. It takes hard work to really think about how to navigate a patient through preoperative preparations, surgery, and postop recovery. It's so much easier and more lucrative to just sit in the operating room and push syringes of drugs while a computer automatically charts all the vital signs. We're being paid to do nurses work while making a doctors salary

Is it any wonder that surgeons look on with disdain when they peer over the ether screen and see anesthesiologists staring at their cellphones? Do you think surgeons care whether the person on the other side of the screen is a physician anesthesiologist or nurse anesthetist as long as somebody is paying attention to their patients? It's only a matter of time before the insurance companies and hospital administrators realize this too and make their own adjustments.

16 comments:

  1. The problem is anesthesiologists make it LOOK too easy. Because we plan and prepare to set up for success. This isn't unique to anesthesiologists. Many physicians do this as well. Internists can make their job look very easy. So can surgeons. It doesn't mean it's a glorified nursing job. To make things look easy we also have to be in control. I hate it when sometimes in OB the ob nurse wants to hang medications, even worse if they do it without asking me first in a c section.

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    1. Another analogy is a pilot flying by autopilot. Would you say anyone could fly the plane?

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    2. I think a better analogy is a junior copilot. Both pilots are trained to fly but the senior pilot has way more experience when s*** hits the fan.

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  2. Interesting you write this entry considering the tagline of your blog is "Anesthesiologists, there are no substitutes." Do you not take any pride in your work?

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  3. How anesthesiologists see ourselves and how cost cutting insurance companies and hospital administrators value our services are two very different things.

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  4. What's wrong with being a nurse? One important realm where MD anesthesia folks really excel is with regional and spinal anesthesia. I'm paranoid about losing consciousness and had outstanding regional anesthesia from a very understanding and super competent MD. I suspect that a CRNA would have just knocked me out.

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  5. Nothing wrong with being a nurse. Unless you went $400,000 in debt to become a doctor.

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    1. WOW..that's some really big bucks. After paying $600 for my first year of diploma nursing school a kindly surgeon paid for the other 2 years and I happily became his scrub nurse. One of the best deals I ever made!

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  6. Looking from Europe, there is one huge difference on the other side of the pond - here, unlike the US, anesthesiologist in general cover intensive care, and act as consultants for critical patients. When we accept them, we are in charge.

    In my humble opinion, it is why nobody is messing with us nowadays. And really no one, even the most uneducated patient, is not considering us a kind of nurse.

    Respect comes from calling us, when brownie hits the fan.

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  7. My guess is that Dr. Siebert, who is an academic anesthesiologist, rarely does any of the work she is quick to criticize. She likely has residents "doing" her cases, so my question is....what is she doing during those cases?

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  8. Academic anesthesiologists have a lot of lofty suggestions for our role in patient care and at the same time they train and use nurse anesthetists in their institutions. I remember doing preposterous for Student nurse anesthetists when I was a resident in the 1980’s!

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  9. The leadership of our specialty is populated by like minded academics. The same academics who trained multiple generations of physicians to administer anesthesia. Not to supervise, or to rubber stamp or to be a fire fighter to a nurse's practice.

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  10. I agree that most Anesthesiologists could present themselves as more involved in patient care by not doing anything that could be suspected as non-patient care related activities like looking at their cell phones .
    However, it is offensive to state that we are doing a nursing job by drawing our drugs...I would not do it any other way. I want to be responsible for my own drugs and have more confidence that those drugs are what they are labeled with. Regarding antibiotics, I have no beef with that either because we have an obligation to make sure they are given at the appropriate time.
    Way to put down our practice while trying to make the specialty relevant.

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  11. As Dr. Sibert pointed out, no other physicians draw their own drugs or mix their own antibiotics. I don’t think they consider themselves less as physicians because they don’t do these tasks that nurses can do just as well.

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  12. Your article is inconsistent. It almost seems like the goal is simply to be provocative. It reads like you are of two minds on the subject. Drawing up drugs isn't "a nurse's job". Phones in the OR is a wholly, separate subject. The distillation, however, is unfortunately and painfully obvious. The onus is on the doctor to conduct him/herself as such. When our positions are abdicated through laziness, lack of personal responsibility, box checking instead of treating, and unwillingness to learn, adapt, grow and work hard, the role will be filled by others who will.

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