Why would we want to change a practice with a track record that has proven safe and that works well?

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2 Good morning, Mr. Chairman and distinguished members of the House Professional Licensure Committee. My name is Dr. Erin Sullivan. I am president of the Pennsylvania Society of Anesthesiologists and a board certified, practicing cardiothoracic anesthesiologist in a tertiary care hospital for a large health care system in Pittsburgh where I teach and train residents and fellows in anesthesiology as well as directly supervise nurse anesthetists (CRNAs) and instruct student nurse anesthetists (SRNAs). I also practice direct hands-on anesthesia. Thank you for affording us the opportunity to provide testimony on both HB 341 and HB 1256 today and comment on the proposed expansion of the scope of practice of nonphysician anesthesia providers and its implications with regard to patient access, cost and,, most importantly, patient safety. HB 341 uses the term "cooperation" and HB 1256 uses the term "collaboration" but there is no meaningful difference between the two both in practice and as defined. Both terms would have the same effect: to eliminate the longstanding requirement for physician supervision of nurse anesthetists and allow them to practice independently. With regard to our concerns about that proposed change, there is no difference between cooperation and collaboration and no difference between the two bills. I recently had the opportunity to testify before the House Insurance Committee at Chatham University in Pittsburgh on May 2, During that hearing, the President- Elect of the Pennsylvania Association of Nurse Anesthetists, Dr. Arthur Zwerling, who is a nurse anesthetist with a Doctor of Nursing Practice degree, testified that CRNAs should have independent practice, that is, they should be able to practice without any physician direction or supervision and without a physician being available to a patient during their anesthesia care. Asked by Representative Micozzie if there was something in the education process of anesthesiologists that makes them more valuable than CRNAs in an operating room setting, Dr. Zwerling answered "Absolutely not" and that "In most settings", anesthesiologists are not needed at all. Asked when an anesthesiologist would be needed, he answered: "In academic anesthesiology centers where they want to continue to prepare anesthesiologists for practice". In short, he said that anesthesiologists are superfluous physicians whose only use is to train other unneeded physicians. Finally, he testified that the education of a CRNA is equivalent to that of an anesthesiologist even though the average education post high school is seven years on average for a CRNA and years of education for an anesthesiologist. My colleague, Dr. Joseph Answine, and I are here today to discuss the importance of maintaining physician supervision of CRNAs and access to physician anesthesia care for our patients. First, I would like to briefly acquaint you with my educational background. I attended Louisiana State University in Baton Rouge, Louisiana for four years and received my Bachelor of Science degree in biochemistry. I then attended four years of medical school at Louisiana State University School of Medicine in New Orleans, and received my Doctor of Medicine degree. I decided to pursue a career in anesthesiology and entered a

3 four-year residency-training program at the University of Texas Health Science Center at Houston in Houston, Texas. Upon completion of this training, I pursued an additional year of subspecialty training in cardiothoracic anesthesiology and critical care medicine. During my anesthesiology residency training alone, I had taken care of more than 1,000 patients. This figure excludes the few hundred patients that I cared for during my internal medicine internship and the 300 patients that I cared for during my cardiothoracic anesthesiology fellowship training. During my residency, I was required to participate in a specified number of cases and months of training in each of the recognized subspecialty areas of anesthesia, such as cardiothoracic, neurosurgical, pediatric and obstetric anesthesia as well as acute and chronic pain management and critical care medicine. CRNAs do not have remotely that exposure to anesthesia, in depth or breadth or numbers or years, and, of course, they have no training comparable to that physicians receive in medical school. Having then finally completed my subspecialty training, 13 years after I began college and 9 years after I graduated, I have practiced anesthesiology for the past seventeen years, nine of which have been in Pennsylvania. I can state with absolute certainty that every aspect of my education, even my undergraduate studies and without question my medical school, residency and fellowship training, is important to the care of my patients every single day. It is obvious, I think, that 4 years of nursing school and 2-3 years of nurse anesthesia school are NOT equivalent to the training my anesthesiologist colleagues and I underwent. As one of the American Society of Anesthesiologists Legislative Chairs pointed out, a BS in nursing is no different from a BS in English or Physical Education There is a reason why anesthesiologists (and all physicians) go to medical school before their residency training and it is not just to decide which specialty they want to practice. It is because what you learn in medical school provides an important knowledge base for all further specialization. There are many initiatives in the Governor's Health Care Reform plan that the Pennsylvania Society of Anesthesiologists is ready to support. However, HB is not one of these initiatives. HB would expand the scope of practice of CRNAs, granting them independent practice and, in doing so, would remove the current requirement for physician supervision of CRNAs. This would likely result in fewer patients receiving anesthesia care that is supervised or delivered by an anesthesiologist. The Pennsylvania Society of Anesthesiologists strongly believes that the best way to provide optimal and safe care for our patients is by use of the long-established anesthesia care team. By an anesthesia care team, I mean a group of professionals, including anesthesiologists and CRNAs, who together provide care under medicallphysician direction. A proven track record supports the efficacy of this approach. All scientific data gathered over the past forty years have demonstrated that the best patient outcomes from anesthesia care occur when an anesthesiologist is involved with the direction or supervision of patients' care. A 2000 study of 217,000 Medicare surgical patients in Pennsylvania concluded that complications led to 2.5 more deaths per 1,000 cases when an anesthesiologist was not involved in the medical direction of anesthesia in surgery. Medical direction of anesthesia care has been the Federally mandated standard for nearly thirty-five years and this practice has proven highly safe and effective for our patients.

4 Why would we want to change a practice with a track record that has proven safe and that works well? You may be aware that there is a small shortage of both anesthesiologists and CRNAs in the Commonwealth of Pennsylvania and, in fact, this combined shortage exists on a nationwide scale. But anesthesiologists are available in greater than 96% of Pennsylvania hospitals. In those few hospitals or ambulatory centers where an anesthesiologist is not on staff, the operating physician provides the necessary medical supervision of the CRNA. While that situation is not ideal, these surgeons have some anesthesia training and a broader medical background that allows them to direct anesthesia administration in some circumstances. This is comparable to when emergency physicians perform some surgery although they are not board-certified surgeons. Expanding the scope of practice of CRNAs will not improve patient access to care. Nor will expansion of the scope of practice of CRNAs decrease costs. The use of nonphysicians to administer anesthesia does not now and will not likely save patients or insurers any money! As a matter of fact, the Pennsylvania Association of Nurse Anesthetists supported the introduction of legislation in the House in each of the last two legislative sessions mandating equal payment for their services. (HB 2883 of 2006 and HB 801 of 2007). The current insurance payment for providing anesthesia is identical no matter whether it is provided by a physician or by a non-physician supervised by an anesthesiologist or the operating surgeon. However, since anesthesiologists provide additional preoperative, intraoperative and postoperative medical services as a part of their care without extra payment that CRNAs do not (and in some respects are not trained to provide), an anesthesiologist's provision of anesthesia care is often most cost-effective. In 2000, the president of the American Association of Nurse Anesthetists stated in a Congressional hearing that anesthesia nurses do not diagnose or treat postanesthesia complications, including those that occur in the recovery room where anesthesiologists do exactly that. That is consistent with the fact that in Pennsylvania CRNAs are not currently licensed to diagnose and treat and in many instances are not trained to do so. Complete and safe anesthesia care of a patient requires ongoing medical judgments and assessment, sometimes quite sophisticated ones requiring a broad medical base of knowledge, from before surgery begins until the patient fully recovers. Only an anesthesiologist, providing or supervising the anesthesia care, can provide this kind of care. Would you rather have a doctor or a nurse in charge of your care if you were having a serious problem like a heart attack in the Emergency Room or Intensive Care Unit? Why would you want anything less when you are undergoing anesthesia and surgery in the operating room? It is an outdated misconception that "giving anesthesia" is purely a technical function. To the contrary, providing anesthesia care is a much broader and more complex task than the task of "giving anesthesia" per se. Providing that care properly requires broad medical knowledge and the ability to make sophisticated medical judgments based on that knowledge, sometimes in a pressured-filled short period of time when the consequences of an error or misjudgment can be substantial. At the same time, the practice of anesthesia does include functions and responsibilities that can be

5 effectively performed by one of several non-physician practitioners, such as CRNAs, extending the availability of anesthesiologists and allowing us to function more efficiently at tasks that require our skill and training. When we are working under the anesthesia care team model, anesthesiologists are present for all key portions of the patient's care (e.g., taking the medical history, performing the preoperative examination; deciding if it is in the patient's best interest to proceed with the planned procedure or recommending further optimization of the patient's condition; discussing the options for anesthesia with the patient and informing them of any potential risks and benefits; placing special monitors like central and arterial lines; placing spinal, epidural and nerve blocks to minimize the pain of surgery; being physically present at the time that the patient goes to sleep and wakes up from anesthesia) and are available within seconds during the entire time that the patient is in the preoperative holding area, the operating room and the recovery room. A significant number of anesthetic and surgical complications can be prevented by the proper medical decisions, therapy and preparation before, during and after the actual surgical procedure begins and ends. This is most optimally and safely achieved by maintaining the direct involvement of anesthesiologists in the care of our patients. In conclusion, the Governor's proposed plan for Health Care Reform contains some points of merit. However, when it comes to HB , removing the requirement for the supervision of CRNAs by a physician, ideally an anesthesiologist, with the misconceptions that this will improve patient access to anesthesia care, decrease the cost of anesthesia services and improve patient safety and quality of care, places the care of our patients and their successful surgical outcome on a slippery slope into the unknown. The anesthesia care team, with an anesthesiologist or in rare instances another physician at the helm, is the safest and best way to care for our patients and this method has a proven track record. At the last hearing before the House Insurance Committee, the President-Elect of the PANA testified that nurse anesthetists don't need anesthesiologists. I can only respond that while some CRNAs may not think that they need us, our patients do need us! Please maintain our patient's access to the best and safest anesthesia care by continuing to require supervision of anesthesia care by an anesthesiologist or operating physician. Mr. Chairman and members of the House Professional Licensure Committee, on behalf of the Pennsylvania Society of Anesthesiologists and most importantly, on behalf of our patients, I thank you for your time and attention.

6 Clinical and Classroom Training Summary - Nurse Anesthetists and Physician Anesthesiologists Training BSN or RN I BS or BA I I Classroom Instruction Hi& --- School Chemistry for Health Professions; Anatomy & Physiology; Foundations of Nursing Care; Pharmacology; Speech, English Social Sciences Psychology; Nursing care for Mothers, Newborns, & Children: Mental Health, Aging Adults Practical Nursing Practicum I Training I I Degree Training Length (%I Pre-Requisites Classroom Instruction Practical Training MSN or CRNA 2-2 % (some CRNA programs require 2 years working as an RN) BSN or RN Nursing; Physiology; Nursing Pathophysiology; Basic Principles of Nurse Anesthesia; Pharmacology of Anesthesia; Chemistry and Physics of Anesthesia; Professional Aspects of Nurse Anesthesia; Research Methods Nurse Anesthesia Practicums High School Biology; Cellular Biology, Physics, Inorganic Chemistry, Organic Chemistry; Biochemistry; Calculus; History; Social Science; English; Sociology; Philosophy; Psychology MD or DO BS or BA Anatomy; Physics of Anesthesia and Monitoring Systems; Pharmacology; Organ Systems -- Respiratory, Cardiac, Vascular, Neurologic, Endocrine, Digestive, Hematologic, Muscular; Painful Diseases; Critical Care Medicine; Surgery, Anesthesiology, Obstetrics, Gynecology; Pediatrics, Orthopedics Ophthalmology; Cardiology; Pulmonary; Neurology; Endocrinology; Nephrology; Hematology; Oncology; Infectious Disease; 4

7 Length (yr) Pre-Reauisites 1 Classroom 1 Instruction Not Applicable MD or DO Degree Anesthetic Techniques: General, Spinal, Epidural, & 1 Regional, Invasive Monitoring; Echocardiography; Neuro Monitoring; Cardiac Anesthesia; Pediatric Anesthesia; Obstetric Anesthesia; Critical Care; Acute & Not Applicable EDUCATION- I school)