The Independence debate in Anesthesia

The independence debate in anesthesia. #anesthesiologist #physician @nmsahq @asahq Physician-led anesthesia care team provides patient safety, which is the #1 priority in patient care. #va #patientsafety #healthcare

The physician vs. crna debate has reared its ugly head…. yet again.  There have been multiple bills presented to suggest crna independence WITHOUT physician anesthesiologist oversight.  In 2017, proposals were made to the Veteran’s Affairs to replace physicians with crnas.  Here’s what they found when they looked at the VA databases to conclude that nurses will continue with physician oversight in anesthesia:

Current laws in 45 states and the District of Columbia all require physician involvement for anesthesia care and the VA in 2017 decided to maintain its physician-led, team-based model of care. The VA’s Quality Enhancement Research Initiative (QUERI) could not discern “whether more complex surgeries can be safely managed by CRNAs, particularly in small or isolated VA hospitals where preoperative and postoperative health system factors may be less than optimal.”

Here’s my evidence and reasons why I believe the care of the patient is best when it is physician-led.  After all, would you want a nurse or assistant doing your actual surgery?  The ultimate goal is patient safety.

Physician anesthesiologists have up to 14 years of post-graduate medical education and residency training, which includes 12,000-16,000 hours of clinical training, nearly seven times more training than nurse anesthetists.

From 2010:

From 2011:

From 2017:

 

Yet, here’s another debate that shows there’s no difference in an anesthesia care team setting with an anesthesia assistant and a crna:

Bottom line in my opinion:

  • Physicians endure years of grueling medical education that starts with the why, how, and treatment of disease. This is followed with years of residency training in anesthesia. There’s also further training in the form of a fellowship for specialized fields.
  • Getting into medical school is an extremely competitive process. You take the top 1% of college graduates and high MCAT scores to get into medical school.  The board certification for becoming certified in anesthesiology is quite complex and difficult in both the written and oral board exams.
  • I will continue to be FOR team-based physician-led anesthesia care.

What it’s like to be a female anesthesiologist…

To promote the series #asawoman started by @nataliecrawfordmd (from Instagram)
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Throughout medical school, residency, fellowship, even now in private practice… patients have often judged a book by its cover. They’ve thought I was their nurse, volunteer, high school student or college student shadowing, almost everything but the person who will lead their anesthetic care. While this can seem deflating given all the extra work and studies one puts in to become a physician, I’ve changed my mindset re: my patients’ initial thoughts on me.
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First of all, thank goodness they think I’m super young! I have my mom’s genes and beautiful skin to thank!! At this rate, I hope I start to look 30 when I hit 50. When patients ask my age, I happily oblige them with a bold 39. Then I see a look of relief over their faces. I, of course, ask them how old they think I am….and I get the range of: just graduated college to mid-20s. Awesome!! I use it as a bonding moment and icebreaker with my patients. Sometimes with the right patient, I joke with them that it’s my first day… it usually entertains a good laugh. Then, I go into an overly technical schpeel on risks/benefits of anesthesia, expectations, PACU recovery. This typically solidifies to the patient that it’s not my first day on the job. Additionally, many patients tell me in the PACU that they feel better than their prior experience or better than their expectation and are quite grateful for my care.
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There are a lot of men in my anesthesia group. Sometimes, after I introduce myself to the patient, they’re shocked that a woman anesthesiologist would be delivering their care. In this day and age, I’m shocked that a lot of patients still assume that a male physician will oversee their care. When caring for female patients with this mentality, I purposefully address a gentle and vigilant anesthetic plan. With my male patients with this mentality, often times they’re happy to talk about the “happy juice” cocktail they’ll get and some much deserved relaxation knowing that I will carry a watchful eye over their surgery and anesthetic.
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Lastly, since becoming pregnant with my first and currently pregnant with my second… I feel I have a better understanding of the worried/concerned parents who are at the bedside to be with their child about to enter surgery.  Oftentimes, the parents think I’m young and want to know where I trained and when I graduated.  I offer them this info, and continue speaking to the patient (their child) about their concerns or questions.  I make sure the parents know everything that will go on re: anesthetic plan, how the patient will feel in recovery and risks/benefits of anesthesia options.  I TAKE MY TIME with the parents and the patient.  While my age and gender often work against me (even though it shouldn’t!), I make sure the controllable worries by the parents are addressed.  I speak to the parents after the surgery.  They go into the recovery room and see their child (older than 13 at our hospital) comfortable and recovering.  While I can’t change my appearance (nor would I want to…), I can change perceptions of women physicians.  We are every bit as capable of everything our male colleagues can do.  In addition, we tackle pregnancy, motherhood, businesses, and everything in between.  #asawoman As A Woman, I feel more empowered now than ever before.

Women in Anesthesiology

American Medical Women’s Association

American College of Physicians: Women in Medicine

Bias, Bravery, and Burnout: The Journey of Women in Medicine

Interested in Medical School? Start Early.

A friend of mine’s son is just about to graduate from high school.  He’s interested in medical school, and his mom asked me what advice I would give to help him pick a college knowing that he has an interest in medicine.

Keep in mind: I am not a counselor or an advisor.  I am a physician, and this is what worked for me.

My advice:

  1. If you’re interested in medicine…. start early.
    • The college and medical school application process are getting more competitive.  Students are bright, prepared, and eager.  Let’s start with the basics.  Are you sure you’re interested in medicine?  Like really interested?  Sure, the media portrays some glamour lifestyles for physicians… but it’s not all glitz and glam.  You’ll put in at least a decade of extra work vs. your peers who get a job right out of college.  While they’re building their nest egg, you are not.   
    • Luckily, I stumbled upon my interest in medicine at an early age when my family practice physician encouraged me to pursue it.  He proved to be a great mentor as I was able to shadow him and really get a feel of his day and what he does.
  2. Once you’ve decided medicine in your passion… solidify that decision.
    • Volunteer at the hospital.  Observe your physician.  Volunteer to help people.  If this excites you, you’re on the right track.  Put yourself in situations where you can get involved in medicine.  Read and research what medical school is like.  Reach out to a medical school and see if you can get more information: chat with a medical student, find out if anyone needs help with a research project.
  3. Do well in school.
    • This is a must.  Applicants are incredibly competitive and intelligent with tons of extracurriculars on their resumes.  Get good grades.  Do well on your SAT/ACT and then do well on the MCAT.  Your grades and your test scores are the most basic comparison tool for schools to compare applicants.  Doing well gets you noticed.
  4. Get involved and signup for extracurricular activities.
    • Once you’ve put in the work for good grades and test scores… get involved.  This could be anything: sports, clubs, arts/music, babysitting/caring for loved ones, volunteering, job in a lab, travel/cultural growth.  The key is to show that you’re well-rounded and multifaceted all while achieving the good grades.  Once the colleges and med schools have seen your test scores, they’ll next use your extracurricular activities to help separate out the different applicants.  The key is maintaining good grades while all these other activities are happening.  AAMC fact sheet for medical schools.

If you’re in high school and interested in medicine:

  • Get good grades and do well on SAT/ACT (consider college prep courses to help)
  • If you’re able to take honors classes or AP classes and do well, definitely sign up for these.  It’s another way to separate yourself from other applicants.
  • Volunteer at your local hospital and/or doctor’s office
  • Get a job at a research lab or hospital
  • Get involved in extracurricular activities
  • Talk to your high school counselor about career paths
  • Attend career fairs (my school offered a career night in medicine where we got to go into the operating room) and college fairs on getting into medical school
  • Ask a college pre-med what they’re taking and how to do well in college
  • If you’re torn between two schools on your college list, consider taking a good look at the college that may also be linked to a medical school.  There’s a good chance that some of the medical school professors will be teaching some of the upper level physiology or anatomy college courses.  Some of the professors may also sit on the admissions committee to medical school.  Lastly, it may be easier to get involved in clinical research or scientific studies that the medical school professors are working on… and that would be a great way to introduce yourself to medical school staff as well as get a stellar recommendation letter to show off your work ethic and dependability.

If you’re in college and interested in medicine:

  • Get good grades and do well on the MCAT (consider prep course to help)
  • Get a major in something you’re interested in (you do NOT have to be a pre-med major… you just have to take the pre-med prerequisites to take the MCAT and apply for medical school).  Even though I majored in biomedical science (a pre-med major at Texas A&M), I would have done biomedical engineering if I had a do-over.  Science and math have always been my interests…the engineering major would have given me a nice background beyond my pre-med major.
  • Talk to your college counselor/advisor early (freshman year)
  • If you get into an honors program in college (usually based on your SAT/ACT scores), go for it.  Typically the honors classes are smaller and are a fantastic way to build report with your professor as well as get deeper into the subject matter.  Plus, being in the honors program will further help you standout on your application to medical school.
  • Volunteer at the local hospital.  Although you may start out as a volunteer, see if you can get into the OR (operating room) as well as outpatient clinics.  This will expose you to a wide variety of practices: surgery, anesthesiology, pathology, internal medicine, family practice, OB/GYN, specialties, etc.
  • Get involved in extracurricular activities in college.  There are a ton of clubs and interest groups in college.  If you don’t find one you like, start your own!
  • Need a job in college?  Consider getting one in the research lab or at a medical school or in a hospital.
  • Consider doing summer school to get some credits out of the way.  When I was in college, 12 credits was a full-time student.  I always took 15 credits because I thought I could handle it.  (Now I cannot recommend the following…) My junior year in college, I signed up for 21 credits to see if I could handle a medical school work load.  It was a tough semester, but I did it and got a 4.0.  I wouldn’t recommend that route because you need to focus on grades… but it worked for me.
  • Apply to a lot of medical schools (in-state and out-of-state).  I grew up in Texas and at the time they had a Texas match with 7 medical schools.  I only applied to the Texas (in-state) medical schools because I knew that was all I could afford.  Keep in mind your debt burden: a $9,000/yr education vs a $30,000/yr is a big difference.  I chose an option that made the most sense to me — I didn’t want to be in debt forever.  In fact, I highly recommend reading this book: The White Coat Investor: A Doctor’s Guide To Personal Finance And Investing.  If I had that available to me, I would’ve read that in high school… re-read it in college… read it again in medical school… and read it again throughout life.  Yes, I’m constantly revisiting this book because it is that good.
  • Interviews: honestly, I can’t remember if I interviewed for medical school or not (geez that makes me sound old!).  If you do have interviews… put your best foot forward and practice interviews with your friends/parents/professors/etc.  Be positive, engaging, and professional.  Interviewers DO judge a book by its cover.
  • Once you’ve applied to medical school, sit back and wait for your results to roll in.  Honestly rank the schools you would like to go that caters to your learning style/goals/etc.  My medical school (UTMB) was one of the first in the country to incorporate systems-based learning and problem-based learning.
    • Systems-based = learn subject material based on the different organ systems vs. separate anatomy, physiology, pharmacology, pathology, etc.  (I learned based on the cardiovascular/gastrointestinal/genitourinal/neurological system, which included the anatomy, physiology, pharmacology, pathology, etc related to that system.  I thought it was a more intuitive way to learn medicine) .
    • Problem-based learning involved small groups where we would discuss medical cases, labs, clinical problems, etc.  It was a nice environment to express yourself as well as work together in a team.  This is how the real-world works where you talk to your colleagues to work through various medical issues.  It supports professionalism and engages a teamwork mentality.
  • Lastly, thank the people who helped you get here.  It’s easy to overlook your mentors, friends, professors, and family.  As you enter the medical school/medicine world, your family will learn along the way that you made a commitment to a profession that will take priority over them.  You will miss weekends, evenings, date nights, holidays, anniversaries, etc.  Not only will you sacrifice a lot to get to medical school… you’ll continue making sacrifices once you’re out practicing medicine in the real world.

AAMC fact sheet for medical schools

My Training:

My Job:

Don’t Dismantle the TAVR Heart Team

More and more in our daily lives, we see a push to make things more cost-effective. There are legitimate ways to cut costs, however, I really have trouble seeing any huge gains earned by the hospital when you eliminate anesthesiologists and/or surgeons. People need to look at risk assessment in these cases. What if an already sick patient decompensates during the procedure? Is the cost-effective strategy of eliminating caregivers really the best way to save money? It seems to me that liability would be a greater risk without having a surgeon for a crash sternotomy or an anesthesiologist to manage the airway and physiology.

invasivecardiology

There is global debate how to make TAVR procedures less expensive. Some sites changed from general anesthesia to sedation, some go even beyond that and keep patients fully awake during the procedure. Some sites eliminated anesthesiologists, some even eliminated the surgeons, as well. All this in the name of cost reduction, in exchange of safety, comfort and crucial information if not selected properly. TEE requires general anesthesia, but it can provide invaluable information and we anesthesiologists, can provide tailored and safe anesthesia. In certain situations, like severe lung disease, in experienced hands, sedation could be more appropriate than general anesthesia, even if it means eliminating TEE.
We looked at the cost of TAVR not just as a procedural cost, but as a post-procedural cost. Renal failure following TAVR can occur with underlying renal insufficiency and has significant financial and quality of life consequences. One of the mechanisms for this serious…

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24 hours with an anesthesiologist

A piece I’d like to submit for: CNN Money 24 hours With….an anesthesiologist

About Kris:

I grew up in a small west Texas town called Abilene, TX. My mom was a standard tiger mom in that she encouraged me to pursue multiple activities while nudging me to do my best. After drama lessons, tennis lessons, basketball, volleyball, piano, violin, band, taekwondo, pageants, and just life, I left Abilene and pursued a biomedical science degree at Texas A&M University.  My earliest memory of wanting to be a doctor started when I was in the third grade.  I hadn’t been feeling well and was diagnosed with pneumonia — I had been reading a book called This is the Child.  My family practice physician Dr. Lawson was about to prescribe me prednisone and I immediately got worried because that was the same medication used to help with the child’s leukemia.  Dr. Lawson picked up on my early curiosity and invited me to hang out with him in his medical office observing patients.  After college, med school proved to be a great experience at University of Texas Medical Branch in Galveston and felt like learning on steroids (as compared to college).  My clinical rotations led me to the path of choosing anesthesiology as a career.  Anesthesia is the perfect combination of anatomy, physiology, pharmacology, psychology, and sociology.  I matched into a terrific internship in Austin, TX and continued my anesthesia training at the prestigious Massachussetts General Hospital.  Following 4 grueling years of training, late nights, memorable cases, and lifelong friendships, I chose to pursue a cardiac anesthesia fellowship at University of California San Diego — a world renowned institution for the treatment of right heart failure following pulmonary thrombosis.  14 years after graduating high school, I have the job of my dreams.  Here’s a sample of my day…

My Day:
Today I’m #2 in our call lineup, which means it will be a pretty busy day. Typically, we have 15 call spots in our main operating room (OR) numbered #1 to #15. #1 position gets the first pick of cases. #2 gets the next pick and so on.

5:45a Early heart day wake up. Today, I will be providing anesthesia to a 70-something year old lady who needs a new heart valve.  On heart days, I wake up at 5:45a to be at work by 6:30. And on regular main OR days, I wake up at 6:15a to be at work by 7:00. Ahhhh… To have more beauty sleep!

6:17a Breakfast in the car – it’s either green juice, Shakeology, or banana on the go!

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Breakfast on the go!

6:31a I meet the patient and her family in the pre-operative area.  We go over a detailed plan for her anesthesia as well as answer any questions.  One of the best parts of my job is meeting all different types of people.  It’s an amazing feeling to meet people at one of their most vulnerable moments in their lives and win over their trust and respect.  It is my job to safely manage their physiologic processes.  Oftentimes, patients tell me it is the anesthesiologist who is the most important part of a surgery — they understand how easy it is to bring them close to the brink of death and then revive them back to a wakeful state.  It’s incredible the amount of trust patients place in your hands in such a short time after meeting them.

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7:15am The patient is under anesthesia and all invasive monitoring lines (arterial, central venous pressure, cordis, pulmonary artery lines) have been placed.  The transesophageal echocardiogram is performed and results are relayed to the cardiac surgeon.


7:45am Cardiac surgeon makes incision.  The patient is monitored throughout the case.  Multiple screens show all the physiologic monitoring results.

10:00a Bathroom break! Partners/colleagues break each other out so there is always an anesthesiologist monitoring the patient.  It’s also a good time to grab a snack!

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My work bag with some life saving snacks to avoid hangriness!

11:32a Drop first patient off in Cardiac Care Unit and grab some lunch. The doctor’s lounge keeps us fed with soup and salad. Today, I’m feeling the vegetable soup. Grab a quick bathroom break and then to interview the next patient.

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Lunch on the go!

11:45a Electrophysiology study for atrial fibrillation ablation. The view from this OR is such a delight!

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The view from my little nook.

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14:00 I get a call from our anesthesia czar, one of my partners who runs the schedule. He was wondering if I would make my 15:00 hip replacement. After a quick conversation, we decide that I would call him in 30 minutes for an update.

14:33 We are finishing up with the current case and I call the czar back to find out about my next case. I learned that there is an emergent heart that will be started by another colleague and that I will continue the lineup in EP (so my day went from a 16:30 finish on paper to roughly a 19:00 finish). Anytime I am in the top 5 call positions, I know not to make defined plans because you never know if there will be addons or changes to the schedule. This makes my social life a bit frustrating as my non-medical friends have a tough time understanding and adapting to this “you don’t get out of work at 5p?” concept.


15:20p Drop patient off in the Post Anesthesia Care Unit (PACU). Grab a quick snack and head back to EP for the next patient.

15:25p Speak to the next patient who has arrived for an afib ablation as well. Induce and get started with the case.

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19:22 Drop last patient off in the PACU.  As #2 on the call list, I look at my watch and realize that I am #2 at night.  This means I will be the 2nd person they call tonight if extra rooms in the OR get booked (traumas, heart call, etc.).  As much as I’d love to head home and grab a glass of wine and unwind, I meet up a friend for dinner to catch up and relax.

21:42 Head home. Shower. Brush my teeth and get into bed.  There’s always a risk of being called into work.  Tomorrow will be a shorter day.  After the hectic day, I am still thankful for my wonderful job and colleagues.  Looking back at my journey to get here, I smile because I couldn’t be happier.

24 hours with an anesthesiologist

A piece I’d like to submit for: CNN Money 24 hours With….an anesthesiologist

About Kris:

I grew up in a small west Texas town called Abilene, TX. My mom was a standard tiger mom in that she encouraged me to pursue multiple activities while nudging me to do my best. After drama lessons, tennis lessons, basketball, volleyball, piano, violin, band, taekwondo, pageants, and just life, I left Abilene and pursued a biomedical science degree at Texas A&M University.  My earliest memory of wanting to be a doctor started when I was in the third grade.  I hadn’t been feeling well and was diagnosed with pneumonia — I had been reading a book called This is the Child.  My family practice physician Dr. Lawson was about to prescribe me prednisone, and I immediately got worried because that was the same medication used to help with the child’s leukemia.  Dr. Lawson picked up on my early curiosity and invited me to hang out with him in his medical office observing patients.  After college, med school proved to be a great experience at University of Texas Medical Branch in Galveston and it felt like learning on steroids (as compared to college).  My clinical rotations led me to the path of choosing anesthesiology as a career.  Anesthesia is the perfect combination of anatomy, physiology, pharmacology, psychology, and sociology.  I matched into a terrific internship in Austin, TX and continued my anesthesia training at the prestigious Massachussetts General Hospital.  Following 4 grueling years of training, late nights, memorable cases, and lifelong friendships, I chose to pursue a cardiac anesthesia fellowship at University of California San Diego — a world renowned institution for the treatment of right heart failure following pulmonary thrombosis.  14 years after graduating high school, I have the job of my dreams.  Here’s a sample of my day…

My Day:
Today I’m #2 in our call lineup, which means it will be a pretty busy day. Typically, we have 15 call spots in our main operating room (OR) numbered #1 to #15. #1 position gets the first pick of cases. #2 gets the next pick and so on.

5:45a Early heart day wake up. Today, I will be providing anesthesia to a 70-something year old lady who needs a new heart valve.  On heart days, I wake up at 5:45a to be at work by 6:30. And on regular main OR days, I wake up at 6:15a to be at work by 7:00. Ahhhh… To have more beauty sleep!

6:17a Breakfast in the car – it’s either green juice, Shakeology, or banana on the go!

IMG_6880.JPG
Breakfast on the go!

6:31a I meet the patient and her family in the pre-operative area.  We go over a detailed plan for her anesthesia as well as answer any questions.  One of the best parts of my job is meeting all different types of people.  It’s an amazing feeling to meet people at one of their most vulnerable moments in their lives and win over their trust and respect.  It is my job to safely manage their physiologic processes.  Oftentimes, patients tell me it is the anesthesiologist who is the most important part of a surgery — they understand how easy it is to bring them close to the brink of death and then revive them back to a wakeful state.  It’s incredible the amount of trust patients place in your hands in such a short time after meeting them.

IMG_6883.JPG

7:15am The patient is under anesthesia and all invasive monitoring lines (arterial, central venous pressure, cordis, pulmonary artery lines) have been placed.  The transesophageal echocardiogram is performed and results are relayed to the cardiac surgeon.


7:45am Cardiac surgeon makes incision.  The patient is monitored throughout the case.  Multiple screens show all the physiologic monitoring results.

10:00a Bathroom break! Partners/colleagues break each other out so there is always an anesthesiologist monitoring the patient.  It’s also a good time to grab a snack!

IMG_6884.JPG
My work bag with some life saving snacks to avoid hangriness!

11:32a Drop first patient off in Cardiac Care Unit and grab some lunch. The doctor’s lounge keeps us fed with soup and salad. Today, I’m feeling the vegetable soup. Grab a quick bathroom break and then to interview the next patient.

IMG_6887.JPG
Lunch on the go!

11:45a Electrophysiology study for atrial fibrillation ablation. The view from this OR is such a delight!

IMG_6888.JPG

The view from my little nook.

IMG_6889.JPG

IMG_6911.JPG

14:00 I get a call from our anesthesia czar, one of my partners who runs the schedule. He was wondering if I would make my 15:00 hip replacement. After a quick conversation, we decide that I would call him in 30 minutes for an update.

14:33 We are finishing up with the current case and I call the czar back to find out about my next case. I learned that there is an emergent heart that will be started by another colleague and that I will continue the lineup in EP (so my day went from a 16:30 finish on paper to roughly a 19:00 finish). Anytime I am in the top 5 call positions, I know not to make defined plans because you never know if there will be add-ons or changes to the schedule. This makes my social life a bit frustrating as my non-medical friends have a tough time understanding and adapting to this “you don’t get out of work at 5p?” concept.


15:20p Drop patient off in the Post Anesthesia Care Unit (PACU). Grab a quick snack and head back to EP for the next patient.

15:25p Speak to the next patient who has arrived for an a-fib ablation as well. Induce and get started with the case.

IMG_6915.JPG

19:22 Drop last patient off in the PACU.  As #2 on the call list, I look at my watch and realize that I am #2 at night.  This means I will be the 2nd person they call tonight if extra rooms in the OR get booked (traumas, heart call, etc.).  As much as I’d love to head home and grab a glass of wine and unwind, I meet up a friend for dinner to catch up and relax.

21:42 Head home. Shower. Brush my teeth and get into bed.  There’s always a risk of being called into work.  Tomorrow will be a shorter day.  After the hectic day, I am still thankful for my wonderful job and colleagues.  Looking back at my journey to get here, I smile because I couldn’t be happier.