Vets deserve better than the VA's proposed change for anesthesia
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The quality of care provided by the Department of Veterans Affairs (VA) has been the subject of news headlines across the country for more than two years now.  Unfortunately, the VA is currently considering a health care proposal that would fundamentally lower the quality and safety of anesthesia care for our nation's Veterans by removing physician anesthesiologists from oversight of anesthetic care.

The proposed policy, which was published for public comment in the Federal Register, would change how advance practice registered nurses (APRNs) deliver care at the VA and it's getting America's attention. With only a few days remaining until the close of the comment period, more than 95,000 people have posted comments and observers have called this federal regulatory issue one of the hottest topics in Washington.

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The Federal Register is full of proposals that may seem more exciting or controversial, but I believe this issue has caught the public's attention because people sincerely care about our nation's Veterans and believe their health care should not be compromised.

Americans understand that it would be wrong to lower the standard of care provided to these men and women who have so bravely served our country.

Here's the issue. The proposed policy is one way the VA is trying to improve access to care for patients. The new policy would expand the role of advanced practice registered nurses so they can act like physicians. The advanced practice nurses include nurse anesthetists, who currently work as part of a team with physician anesthesiologists. Under the new rule, physician anesthesiologists would be removed from the team and the operating room, leaving nurses to administer anesthesia and make life or death decisions that frequently occur during anesthesia.

But Veterans aren't waiting for surgery because a physician anesthesiologist isn't available. There is no shortage of physician anesthesiologists in the VA and the change is not needed to improve access to anesthesia care in surgery. In fact, the Undersecretary for Health at the VA, David Shulkin, M.D., has said in several public forums that there is no VA access problem in anesthesia.

This change would abandon a proven model of quality health care where physician anesthesiologists and nurse anesthetists work together as a team to ensure our Veterans get high-quality, Veteran-centered care - the standard of care throughout the country. Is it fair to accept a lower standard of care for those who have served our nation in uniform and are at greater risk for complications any time they go into surgery because they are sicker and have multiple medical conditions?

Research does not support a safe way to implement this policy change for anesthesia care. The VA's own internal review (VA's Quality Enhancement Research Initiative) could not discern "whether more complex surgeries can be safely managed by nurse anesthetists" and concluded that "policy relating to extension of autonomous APRN practice cannot be based solely on the evidence reviewed here." Would anyone want the U.S. Food and Drug Administration to put new drugs on the market before they are proven safe? If not, why should we risk the health and lives of our nation's Veterans with a proposal that is not supported by VA's independent assessment of the data?

As written, the current proposal is not only a solution in search of a problem, it is a solution that will create problems. Those who have risked their lives in combat overseas deserve better than having their lives needlessly put at risk here at home in VA operating rooms.

Although nurse anesthetists are competent and valued members of the anesthesia care team, the education and training of a physician anesthesiologist and a nurse anesthetist just do not compare. A nurse cannot replace a doctor, especially in surgery where complications can happen in seconds and those extra years of education and training can mean the difference between life and death.

We take seriously a recent statement by Undersecretary Shulkin that "A well-run VA health system is essential to the nation and to U.S. medicine." We sincerely hope that Secretary McDonald and Undersecretary Shulkin will speak and act with clarity in their commitment to high-quality, Veteran-centered care and, in the final rule, remove the proposal to eliminate physician anesthesiologists from the life and death decisions that occur during anesthesia care in a surgical setting. Our nation's Veterans have not only earned it, they deserve it.


Daniel J. Cole, M.D. is president of the American Society of Anesthesiologists.