Medical Turf Wars - Doctor, nurse groups spar over who can give anesthesia

Doctors and nurses are fighting over who delivers anesthesia in a conflict over responsibility that is bleeding into other medical practices.

“There’s always been a turf war, especially in California,” said Dr. Steven Bansbach, a Thousand Oaks anesthesiologist, referring to professional organizations representing doctors and nurse anesthetists. “It’s a turf war set up more by the societies than the individuals.”

The tug-of-war focuses on supervision. A Medicare billing rule says nurse anesthetists must be monitored by anesthesiologists or other doctors. A year ago, California became one of 16 states to opt out of the federal provision. Gov. Arnold Schwarzenegger argued that allowing the specially trained nurses with master’s degrees to work unsupervised would improve access to care while curbin costs in rural and some urban hospitals.

Dominoes went flying.

Two physician groups, the California Medical Association and the California Society of Anesthesiologists, filed a lawsuit to block the move. In October, San Francisco Superior Court Judge Peter Busch ruled in favor of the nurses, saying they can deliver anesthesia without supervision. Leaders of the doctors groups argue the ruling will compromise patient safety, particularly in surgeries where complications emerge.

“There’s no question that the more training the provider has, the better off the patient is,” said Dr. James Hinsdale, president of the California Medical Association.

The medical association has also opposed recommendations — driven by the growing shortage of primary care doctors — to let nurse practitioners perform more duties typical of doctors.

Nurses have delivered anesthesia with minimal supervision at many sites — including rural hospitals and outpatient surgery centers — even with the Medicare rule.

The anesthetists are advance practice nurses who’ve worked at least one year in critical-care units before earning master’s degrees. The profession is moving to eventually require more training and doctoral degrees for all new nurse anesthetists.

“We are trained to do everything an anesthesiologist does in terms of open heart, craniotomy, spinals, local anesthesia and general anesthesia,” said Lois Remely, a nurse anesthetist working primarily for plastic surgeons.

Kaiser Permanente uses nurse anesthetists in tandem with anesthesiologists at its hospitals. UCLA Medical Center also uses nurses, as do several other academic hospitals and some military groups. But Ventura County is one of many California regions that rely heavily on anesthesiologists. None of its hospitals uses nurse anesthetists.

Some suggest anesthesiologists who want the best-paying jobs are driving the monopoly. Many surgeons say they want doctors delivering anesthesia because working with a nurse anesthetist increases the chance they’d be targeted in a lawsuit.

The chief medical officer for Ventura’s Community Memorial Hospital said its policy of using only anesthesiologists — who go to medical school and then typically complete four-year residencies — ensures “the most well-trained people.” Said Dr. San Frochtzwajg: “The one thing we all know is that anesthesiologists have more training than nurse anesthetists.”

Few nurse anesthetists are willing to talk to reporters, concerned about retribution. The president of the California Association of Nurse Anesthetists, which fought the doctors’ lawsuit, referred all questions to the lawyer speaking on its behalf.

“We think the safety argument is simply a red herring,” said Phil Recht, association counsel, arguing that while doctors receive broader medical education, they get essentially the same training focused on anesthesia as the nurses.

The issue is access, Recht said. If rural hospitals with few, if any, anesthesiologists can’t use nurses, then their ability to provide care is compromised.

Bansbach concedes 95 percent of what he does can be handled by a nurse anesthetist. It’s the other 5 percent that worries him — situations where patients go into shock because of reactions to medication or their heartbeat shifts or maybe even stops.

The people delivering anesthesia need to diagnose and fix the problem, he said. They need to be doctors.

“In anesthesia, seconds make a difference to a patient,” he said.

Michael Boytim, assistant director of a nurse anesthetist school run by Kaiser Permanente and CSU Fullerton, argued Kaiser has the best system because it uses nurses and doctors in tandem, with one anesthesiologist monitoring as many as four nurse anesthetists.

“We can coexist and work effectively,” he said.

Other advocates of nurses cite a study published this year in the Health Affairs journal, showing complications and deaths haven’t risen in states where anesthetists practice without doctor monitors.

“Supervision really didn’t impact care at all,” said Paul Santoro, president of the American Association of Nurse Anesthetists. “It tends to increase costs and decrease access.”

The California court decision allows hospitals to stay with the status quo, saving money by moving to nurse anesthetists or pairing the two, Santoro said.

Anesthesia War