By Joseph F. Answine, M.D.
A patient may have a single anesthesiologist or more than one anesthesia provider working together as part of an “anesthesia care team.” This “anesthesia care team” consists of both physicians and non-physicians, each with their own specific roles, and these roles should be made clear to the patient prior to giving care.
There are less common situations where a Certified Registered Nurse Anesthetist (or CRNA) is supervised by the operating physician and not an anesthesiologist. Frequently in Pennsylvania, this occurs in free-standing endoscopy centers and with procedures that are classically assumed to be of minor risk.
Anesthesiologists, including Anesthesiology Fellows, are the only anesthesia providers who may practice solo (without supervision) in every state. Click links below to learn more about the responsibilities of the different anesthesiology providers:
An Anesthesiology Fellow:
- Is a licensed physician (M.D. or D.O.) who has successfully completed an undergraduate education (most commonly a B.S. or B.A. degree), a medical education, an anesthesiology training program and possibly a sub-specialty fellowship (12 or more years of education after high school including at least four or more years of training after medical school)
- Provides anesthesia directly, or acts as the director or leader of the “anesthesia care team”
- Always retains the overall responsibility for the patient
An Anesthesiology Resident:
- Has completed an anesthesiology training program and has obtained additional education in one of the sub-specialties of anesthesiology (cardiothoracic, neurosurgical, obstetric, pediatric, pain management or intensive care)
- Undergoes additional training that may be months to years depending on the sub-specialty selected and training program
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A Nurse Anesthetist:
- Is a licensed physician (M.D. or D.O.) enrolled in an accredited anesthesiology training program
- Practices under the supervision of an anesthesiologist
An Anesthesiologist Assistant:
- Is a registered nurse who has completed a training program in nurse anesthesia
- Is most commonly under the supervision of an anesthesiologist
A Student Nurse Anesthetist:
- Is a medical professional who has completed an anesthesiologist assistant training program
- Works under the supervision of an anesthesiologist
A Student Anesthesiologist Assistant:
- Is a registered nurse who is enrolled in a nurse anesthesia training program
- There is significant debate as to whether a Student Nurse Anesthetist should be allowed to provide anesthesia without the continuous presence of an anesthesiologist or nurse anesthetist. However, according to the American Society of Anesthesiologists’ Statement of An Anesthesia Care Team: “… the use of non-physician students in place of fully trained and credentialed anesthesia personnel is not endorsed as best practice by the American Society of Anesthesiologists”
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- Is a health professional who is enrolled in an accredited anesthesiologist assistant training program and, therefore, has completed the necessary coursework required for enrollment
- Is always directly supervised (continuously present in the room) by another anesthesia provider such as an anesthesiologist or anesthesiologist assistant
If an anesthesiologist is not immediately available to supervise the anesthesia care, the operating physician may take over those duties – as long as the requirements of a qualified physician are met based on the Pennsylvania Department of Health regulations.
There is a common misunderstanding as to the expectations of the operating physician when acting as the supervising physician for the delivery of anesthesia care in Pennsylvania. As per the Department of Health Regulations Chapter 123 (subsection 123.6), the supervising physician is expected to:
- Perform accepted procedures commonly employed to render a patient insensible to pain for the performance of surgical, obstetrical, or other necessary but pain-producing clinical procedures
- Support of life functions during the period of anesthesia
- Provide appropriate preanesthesia and postanesthesia management and
- Offer consultation regarding anesthesiology-related patient care, such as inhalation therapy, emergency cardiopulmonary resuscitation, and special problems in pain relief, unless these responsibilities are assigned to another physician
Therefore, based on the above regulation, the operating (supervising) physician takes on a significant amount of overall responsibility. Even more than he or she commonly realizes. In fact, many of these non-anesthesia physicians are quite taken back by the level of responsibility that they are assuming when agreeing to supervise the CRNA.
Here are the appropriate passages from the Pennsylvania Department of Health regulations (Note that currently, in Pennsylvania, anesthesiologist assistants are not licensed to practice.):
§ 123.5. Administration of Anesthesia
Anesthesia care shall be provided by a qualified physician, anesthesiologist, resident, physician in training, dentist anesthetist, qualified nurse anesthetist under the supervision of the operating physician or anesthesiologist, or supervised nurse trainees enrolled in a course approved by the American Association of Nurse Anesthetists.
§ 123.6. Physician Qualifications
(a) Physician anesthetists must be able to perform all of the independent services usually required in the practice of anesthesiology, as set forth in subsection (b).
(b) Independent services usually required in the practice of anesthesiology
(1) Performance of accepted procedures commonly employed to render a patient insensible to pain for the performance of surgical, obstetrical, or other necessary but pain-producing clinical procedures.
(2) Support of life functions during the period of anesthesia.
(3) Provision of appropriate pre-anesthesia and post-anesthesia management for the patient.
(4) Consultation regarding anesthesiology-related patient care, such as inhalation therapy, emergency cardiopulmonary resuscitation, and special problems in pain relief, unless these responsibilities are assigned to another physician who is judged by medical staff peer evaluation to be especially well qualified and is willing and able to assume them.
If the individual performing the procedure is not a physician, a physician must be immediately available as outlined in section 123.7 (subsection c) to supervise the anesthesia care. The appropriate subsection is stated below:
§ 123.7. Dental Anesthetist and Nurse Anesthetist Qualifications
(c) When the operating/anesthesia team consists entirely of non-physicians, for example, dentist with nurse anesthetist, dentist with dentist anesthetist, podiatrist with dentist or nurse anesthetist, a physician shall be immediately available in case of an emergency, such as cardiac standstill or cardiac arrhythmia. The requirement that the physician be immediately available may mean in the hospital or in the immediate proximity of the operative procedure area or within minutes of the operating suite.
Usually, the procedures performed without the presence of an anesthesiologist are considered of minor risk such as endoscopies, and are commonly performed in surgical centers. It has to be remembered, however, that the same vigilance necessary for higher risk surgical procedures has to be present for all anesthetics given, and the presence of an anesthesiologist should always be strongly considered.
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