Does Arnold Schwarzenegger Deserve Better Care Than Our Veterans Do?

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When Arnold Schwarzenegger was governor, he decided that you and I don’t need to have physicians in charge of our anesthesia care, and he signed a letter exempting California from that federal requirement. Luckily most California hospitals didn’t agree, and they ignored his decision.

When he needed open-heart surgery to replace a failing heart valve, though, Governor Schwarzenegger saw things differently. He chose Steven Haddy, MD, the chief of cardiovascular anesthesiology at Keck Medicine of USC, to administer his anesthesia.

Now some people in the federal government have decided that veterans in VA hospitals all across the US should not have the same right the governor had—to choose to have a physician in charge of their anesthesia care.

That’s right. The VA Office of Nursing Services has proposed a new policy to expand the role of advanced practice nurses, including nurse anesthetists, in the VA system. This new policy in the Nursing Handbook would make it mandatory for these nurses to practice independently. Physician anesthesiologists wouldn’t be needed at all, according to this proposal, even in the most complicated cases – such as open-heart surgery.

If this misguided policy goes into effect, the standard of care in VA hospitals will be very different from the standard of care other patients can expect. In all 100 of the top hospitals ranked by US News & World Report, physician anesthesiologists lead anesthesia care, most often in a team model with residents and/or nurses. Physician-led care teams have an outstanding record of safety, and they have served veterans proudly in VA hospitals for many years.

The new policy isn’t a done deal yet. The proposal is open for comment in the Federal Register until July 25. Already thousands of veterans, their families, and many other concerned citizens have visited the website www.safeVAcare.org and submitted strongly worded comments in opposition. I urge you to join them.

Many of our veterans aren’t in good health. They suffer from a host of service-related injuries, and they have high rates of chronic medical disease. Some have been among the most challenging patients I’ve ever anesthetized. Their care required all the knowledge I was able to gain in four years of medical school, four years of residency training in anesthesiology, and countless hours of continuing medical education.

It’s clear, of course, why the VA is proposing the change in the Nursing Handbook. The reason is the scandal over long waiting times for primary care. Proponents argue that giving nurses independent practice will expand access to care for veterans.

But there’s no shortage of physician anesthesiologists or nurse anesthetists within the VA system. The shortages exist in primary care. A solution that might help solve the primary care problem shouldn’t be extended to the complex, high-tech, operating room setting, where a bad decision may mean the difference between life and death.

The VA’s own internal assessment has identified shortages in 12 medical specialties, but anesthesiology isn’t one of them. The VA’s own quality research questioned whether a nurse-only model of care would really be safe for complex surgeries, but this question was ignored. The proposed rule in the Federal Register lists as a contact “Dr. Penny Kaye Jensen”, who in fact is not a physician but an advanced practice nurse who chooses not to list her nursing degrees after her name. The lack of transparency in the proposal process is disturbing.

In 46 states and the District of Columbia, state law requires physician supervision, collaboration, direction, consultation, agreement, accountability, or direction of anesthesia care. The proposed change to the VA Nursing Handbook would apply nationally and would override all those state laws, which were put in place to protect patients.

In Congress, many senators and representatives on both sides of the aisle recognize the need to continue physician-led anesthesia care for veterans. Representatives Julia Brownley of California’s 26th District and Dan Benishek, MD, of Michigan’s 1st District are strong advocates for veterans’ health. They have co-authored a letter (signed by many in Congress) to VA Secretary Robert McDonald, urging him not to allow the destruction of the physician-led care team model as it currently exists within the VA system.

Governor Schwarzenegger’s heart surgery is a matter of public record. He has spoken about it openly on television, and he graciously invited the whole operating room team to his next movie premiere. I was lucky enough to go to the premiere too, because his anesthesiologist, Dr. Haddy, happens to be my husband.

But I didn’t set out to write this column on behalf of my husband. I’m writing on behalf of my father, who is now 93, landed on the beach at Normandy on D-Day, and miraculously survived the rest of the war as a sniper. And I’m writing on behalf of all the men and women who have served our country, and who deserve the best possible anesthesia care from physicians and nurses who want to work together to take care of them. If we don’t defeat the proposed change in the VA Nursing Handbook, they all lose.

Karen Sibert, MD, practices anesthesiology at UCLA Health in Los Angeles, and blogs at apennedpoint.com.

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18 replies »

  1. So you want the opthalmologist/neurosurgeon in the room to interpret the ECG and make the decision to abort surgery? Not a realistic scenario, and not what you’d want. And by the time a code is called, its usually too late. When you call a code in an ambulatory surg. center who responds? The anesthesiologist in these places usually is the senior most medical person in house.

  2. “but I have difficulty believing that things will go well with folks that don’t have the kind of training current ‘physician-anesthesiologists’ have.”

    The anesthesiologist is not the only doc in the room. I would suspect that for surgery the SURGEON is in the room. As well there would be a code called for backup.

  3. Nice post Karen. Peter is right, you don’t need an anesthesiologist as long as everything goes right. How exactly does one ensure that? An example that I think John is asking for: If someone has a heart attack during the OR (this can happen in an ambulatory center as well) the tell tale signs may be a slightly higher requirement for medicines to keep your blood pressure up, or the telemetry strip that’s running may show subtle depressions that can be missed even by the most experienced physician. The treatment in this case may not be more fluid or increasing medicines to maintain blood pressure, but stopping the case to do an ECG, or if available to place an ultrasound probe into the stomach to look at heart function. The ECG would require interpretation to make a call on rushing the patient to the cath lab. From the moment a vessel is occluded feeding heart muscle, you have about 90 minutes to open that artery to prevent a large heart attack. Again, even in the best of hands, all may not go well… but I have difficulty believing that things will go well with folks that don’t have the kind of training current ‘physician-anesthesiologists’ have.
    I absolutely agree with Karen here – a physician needs to be involved as part of the care team…if things start to go wrong, you want our best available to help. And those clamoring for evidence? I’ll accept nothing but a randomized control trial with physicians completely removed from the process in this case – and I won’t be signing informed consent for that. Perhaps we can enroll Peter 🙂

  4. I want to choose my anesthesiologist (with input from my primary care doc and surgeon)…..and I would like to be able to pay more for a more experienced doc, or pocket the savings (in my health savings account) if I choose a less costly/experienced provider.

  5. Or maybe, “Doesn’t everyone deserve the most expensive care someone else can buy for them?”

  6. Perhaps the question instead should be: doesn’t everyone deserve a physician anesthesiologist leading their care team?

  7. It makes a huge difference when something unusual happens during a case, and a different level of education is required to sort out the diagnosis. I wrote this blog post, “In anesthesia, knowing when to call for help is key”, to help clarify exactly that issue:


    The expectation for a nurse is to recognize a problem and summon a physician. But when there’s no physician, then what?

  8. “It depends on state law. Not required in all states.”

    Well I guess the VA is no better or worse than most states. If the rest of us can live though surgery with an NA why can’t veterans?

  9. If the nurse anesthetist is supervised by an anesthesiologist, both are liable, but the physician anesthesiologist shoulders primary responsibility. If the nurse anesthetist is practicing independently, then the liability belongs to that individual alone. In states where a surgeon is considered to be providing medical direction to the nurse anesthetist, and no anesthesiologist is required or involved, then there is always a liability argument when complications arise as to who is captain of the ship. The surgeon tends to argue that he/she has no specialized knowledge of anesthesia, and the nurse anesthetist tends to put forward the “captain of the ship” defense that the surgeon is primarily responsible. It all depends on state law in the individual state. And yes, there are many cases!

  10. It depends on state law. Not required in all states. But even when not required by state law, most major hospitals require anesthesiologist supervision per their own bylaws. That’s why the top hospitals all have physician anesthesiologists leading the care team.

  11. Oh, and a quick follow up –In cases where a nurse anesthetist is involved, who does liability live with? Do we have any idea? Are there any cases yet?

  12. Karen

    Thanks again for another great, detailed post.

    Can you give us a short list of potentially serious complications where an anesthesiologist might make all the difference? I’m not sure people get it.

    It would be helpful for people who don’t have your background.

    Much of the demand for reform here stems from the VA wait times scandal, which as I’m sure you know was as much about people trying to keep their numbers up in the face of possibly unrealistic demands from Washington as it was anything else ..

    My guess is that this will be all well and good until the day a veteran dies. Complaining about delays is one thing. Wait until the outcomes are really bad ..

    ./ j

  13. I didn’t think an NA was allowed to practice without at least one anesthesiologist on board?

  14. Again, I’m not saying anything whatsoever against nurse anesthetists, and agree completely that they are valuable members of the team. I’m simply advocating AGAINST removing physicians from the team. It’s a question of right resources in the right place. This VA proposal would mandate independent nurse practice, period. No physicians necessary. Is that a standard of care that high-risk patients deserve, without their having any choice in the matter?

  15. Karen, there are very competent nurse anesthetists doing great work every day. Maybe “open heart surgery” should not be where they are used, but there are plenty of surgeries that can be done as well as or better without the high priced help.

  16. “The VA Office of Nursing Services has proposed a new policy to expand the role of advanced practice nurses, including nurse anesthetists,”

    “If this misguided policy goes into effect, the standard of care in VA hospitals will be very different from the standard of care other patients can expect.”

    Really??? My hip surgery was with a nurse anesthetist (NA). We have a friend who is an NA in private care hospital, has been for many years at different hospitals. She works under a anesthesiologist doc, probably doesn’t have to, but you know – the pecking order.

    Why should the VA be any different?

  17. Sorry–there’s no such thing as a nurse anesthesiologist! I’d like to see who would agree to be in the double-blind study of having high-risk surgery–open heart, vascular, lung–with a nurse alone vs. a physician in charge of the anesthesia. Would you? Team-based care has a long record of safety in anesthesiology. If a person wants the responsibility of a physician, I recommend medical school.

  18. I think anesthesiology is a very rich and deep knowledge base that has to have a full medical school background and two to three years of residency to gather experience and expert advice; but nurses and people who want nurses votes and people who want to reduce costs don’t feel this way. So it becomes a political battle and all we can do is fight it out. The economists all howl “barriers to entry” as if no barriers are ever needed. But they do not want to fly commercial airlines with a “nurse” pilot….so there are some barriers that are justified and hypocrisy runs amok.

    But, in this fight, you have to study the incidence of misadventures in the nurse anesthesiologists vs the MD anesthesiologists. Enough careful studies from great research teams will finally tell us the right way to go. This dilemma is really old and goes back to the ’50s. It’s like dentists vs dental hygienists, who want to be independent….always fighting.