Central Line

Episode Number: 160

Episode Title: Physician Led Care

Recorded: April 2025

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Welcome to ASA’s Central Line, the official podcast series of the American Society of Anesthesiologists, edited by Dr. Adam Striker.

DR. ADAM STRIKER:

Hello, and thanks for joining us again today for Central Line. I'm your host and editor, Dr. Adam Striker. Today it is a special treat because I am joined by my good friend and mentor, Dr. Kathy Perryman, who has unique insights into the role of both anesthesiologists and nurse anesthetists, and certainly well situated to share her rare perspective on the value of physician led care. Dr. Perryman, thanks for joining us.

DR. KATHY PERRYMAN:

Well, thank you for having me, Dr. Striker. I appreciate it, and I admire all the things that you've been able to do through your career.

DR. STRIKER:

Well, that's very kind of you. Thank you so much. We usually start off these conversations by having the guests talk a little bit about their background. So why don't you go ahead and tell our listeners a little bit about your, uh, unique background up to and including serving as past president, Missouri Society of Anesthesiologists.

DR. PERRYMAN:

Well, yes, I do have a little bit of a unique background. I was an ICU nurse first. That was my first career. Then I became a nurse anesthetist. After I worked as a nurse anesthetist for three years, I decided to go on to medical school, and I wasn't sure if I was going to stay in anesthesia or switch to another, like pulmonology or or neonatology, but I ended up rediscovering how much I loved anesthesiology. So I went to medical school and did a residency and fellowship. And then after my fellowship came back and joined the same group that I had been in as a nurse anesthetist, which was also unique. I, uh, worked on the cardiac anesthesia team there for 30 years. I had the opportunity to do many leadership opportunities in my career. I chaired the credentials committee for a long time, and it was the chief of anesthesiology in my hospital. I started several initiatives like pre-admission testing, and I was the laser safety officer and started out of the OR sedation, then became the president of the medical staff and was on the executive committee. Alongside of that, I was also working in the ASA on committees and was part of the Missouri Society of Anesthesiologists starting in the 90s. I became very active and was president of the Missouri Society of Anesthesiologists in the early 2000. So I had a lot of opportunities for leadership roles and took advantage of it and loved it. I worked there for over 30 years before I retired, so it's been quite a long, wonderful career.

DR. STRIKER:

Well, I'd be remiss not to give you profound credit for getting me involved into the ASA, probably more than any other factor, given your leadership.

DR. PERRYMAN:

Well, I'm so glad you did that. You've made quite the impact, so thank you.

DR. STRIKER:

Well, no. Thank you. You certainly have been a great example to to many, many practicing anesthesiologists with your leadership and certainly a storied career. But let's dial back just a little bit. You worked as a nurse anesthetist obviously, prior to becoming an anesthesiologist. What drew you to anesthesiology in the first place? And maybe talk a little bit about what the motivation was making the leap from being a nurse anesthetist to an anesthesiologist. What was the nidus for that?

DR. PERRYMAN:

Okay. Well, the attraction to being a nurse anesthetist was a suggestion by my then brother-in-law, who was a physician, because he knew I wanted to further my education and become more involved in doing patient care myself. So he suggested that, and I went on to do that and I enjoyed it. But I recognized that I wanted and I needed the additional education and training to gain the knowledge base and skills that were required to be capable of safely caring for patients on my own. My husband was a physician. My brother-in-law was a physician. So I knew in my personal life people that worked as physicians and then the ones who supervised me, obviously to me, they had a larger knowledge base and skill set than I was able to achieve when I was in nurse anesthesia school and in practice. So because I knew that I could only practice safely with the oversight of a physician who had those advanced skills and knowledge, and I wanted to be that physician. I applied to medical school, and I had the full support of the anesthesia group that I worked with. They were so wonderful. They just were great supporters.

DR. STRIKER:

Well, I want to talk about a couple aspects of all this. Right now, I'm going to leave aside the difference in maybe how practice has changed over some time. Before we get to that, why don't you talk a little bit specifically about what you view as how these roles differ? I mean, maybe the roles have changed a little bit over the years, but you're in a great position to look at how being a physician and anesthesiologist role versus a nurse anesthetist differs, and where it makes a difference, I suppose, to become a physician.

DR. PERRYMAN:

Okay. As a student nurse anesthetist, I learned basic pharmacology, pertinent anatomy and physiology, and airway management skills, things like that. As I had anticipated, my medical school education content included anatomy, physiology and pharmacology in much more depth. This extended to multi-system disease processes and learning how to appropriately diagnose and treat patients. My first year in residency was extremely valuable in exposing me to this multi-system disease processes again, and learning how to appropriately diagnose and treat patients under the leadership and teaching of subspecialty physicians. Then, in my anesthesiology residency, I learned so much patient care medical evaluations, patients to determine their preoperative risk factors, determine their needs and readiness for surgery, and develop the appropriate anesthetic plan for each patient. I also learned advanced airway management and much more in-depth anesthetic pharmacology and pain management, as well as learning to respond to emergencies to immediately diagnose and intervene to treat the problem. So there's such important information learned in each one of these roles, but it's very different. In addition to the information this learned, there's not enough time in two and a half, three years of nurse anesthetist training to learn the same depth and breadth of information that you can learn as an anesthesiologist who has 12 to 16,000 hours of patient care training, compared with maybe 2000 and 2500 hours of patient care training for nurse anesthetists. So the contrasts, I think I've outlined. Do you have any more questions about the contrast?

DR. STRIKER:

No. I think you did a great job in articulating the differences between the two. The other question I wanted to ask then is, do you feel that the role of a nurse anesthetist has changed over the years from when, when you left that particular profession to become a physician, compared to today, or when you most recently practiced? Do you feel like the nurse anesthetist role has expanded? Has it evolved? Has it changed in any way? What have you been your observations over the years?

DR. PERRYMAN:

I taught residents and nurse anesthetist students for decades. And as the chief of the department, I worked with leadership in the nurse anesthetist programs as well in that role. And what I was told by others about a student had told them in the first several months of school that they would be equal to anesthesiologists when they finished, and that they wouldn't need supervision. I also spoke with colleagues who still train nurse anesthetists in their institutions and in the schools that are in our area. And they agreed that most nurse anesthetists. It's been my experience, too, when I was working, that most nurse anesthetists are very collegial and want to be part of the team and want to work together and understand the relationship. But what's changed is the leadership. And so there's a smaller percentage of nurse anesthetists that have that same attitude that they're being taught that isn't team oriented. It's independent oriented.

DR. STRIKER:

You know, I've worked with plenty of talented nurse anesthetists over the years, and I continue to work with some really brilliant nurse anesthetists who have just been not only a pleasure, but just such a help. Yes, to the job that I'm currently doing. Do you feel like the expertise or the breadth of what nurse anesthetists are taught or practicing now has has evolved over the years.

DR. PERRYMAN:

Well, I think it it evolves along with everybody else's medical practice knowledge base. What they're learning is more advanced, like line placement and things like that is more advanced than what I learned when I was a nurse anesthetist. But they still don't have the time to learn the same breadth and depth of information. They don't have the skills to do a multisystem diagnosis and plan a treatment plan outside of an anesthetic. And the anesthetic plan is not in the same depth as an anesthesiologist because of that continued difference in their knowledge base, because they don't get to do an internship and be on a cardiology rotation and things like that, like anesthesiologists do.

DR. STRIKER:

How did you perceive the surgical anesthetist or surgical anesthesiologist interaction from when you were a nurse anesthetist to when you became an anesthesiologist? Was there a difference? Did you notice a different kind of collaboration, or did you find the discussions to be different? Could you perceive a difference in the perhaps medical collaboration?

DR. PERRYMAN:

Well, yes, because the surgeons knew that I relied on the anesthesiologist for acute decision making and diagnosis and treatment or planning and management before and after the procedure. When I became an anesthesiologist, the collaboration between the surgeon and the anesthesiologist in most cases is very obvious, and it's an integral part of the patient's care. So I you know, I think most people feel like the surgeons want the input of the anesthesiologist and really need it for planning and and care of their patients.

DR. STRIKER:

What do you think anesthesiologists should understand better about CRNAs? And likewise, do you think there's things that CRNAs should better understand about anesthesiologists?

DR. PERRYMAN:

Well, I think they both appreciate each other's skill sets and how they can work as a team together. And I think that needs to be supported and fostered in an ongoing basis so that nobody feels rebuffed or alienated. The nurse anesthetists need to understand that they're a very valuable part of the team, so that we can provide patient care to many more patients than if it was just anesthesiologists by themselves. The team makes patient care safe. They've got to talk to each other. I think you have to make it a habit to talk, collaborate and help each other understand how important the teamwork is.

DR. STRIKER:

You feel the physicians sometimes don't do a great job of bringing the nurse anesthetists in to the medical plan as much as they could?

DR. PERRYMAN:

I think there are so many personalities across the board in every specialty and in, you know, both sides -- nurse anesthetist and anesthesiologist. Yes, I think that we have to strive to communicate well. It's for the benefit of the patient. But I've seen anesthesiologists that take that for granted and don't communicate well enough with their nurse anesthetist. And I've seen the opposite too: nurse anesthetist that just don't want to talk or listen. They just want to be left alone.

DR. STRIKER:

Well, let's use that as a segue to discuss the care team in general. I know you're a proponent of physician led care and the anesthesia care team as an entity. Um, and I know many of our listeners share that as well. Why don't you talk a little bit about that model and why you feel it's best for patients.

DR. PERRYMAN:

Well, as I mentioned, it does improve manpower, and nurse anesthetists have a very long history of providing anesthesia care all over the United States, and it has mostly been done in a care team model. And anesthesiologists have the educational background and the skill set to provide the leadership for that care team. So I think it's been shown that an anesthesiologist supervising in a care team model is safer than without supervision.

DR. STRIKER:

You mentioned before, we touched briefly about how, you know, anesthesiologists could do a better job of communicating with their nurse anesthetist colleagues on a given patient. That probably plays into maybe the best approach for the supervision of nurse anesthetists. But do you see any other aspects to that, that relationship? In other words, how do physicians ensure that that care team model works the best for the patients and also for all the the clinicians as well?

DR. PERRYMAN:

Well, I think they have to take responsibility and do the preoperative assessment and plan and communicate that very nicely to the rest of the anesthesia care team. Then they need to not be overbearing, but be solidly present and available for any kind of discussion about the intraoperative care. And then they need to be in charge of the post-operative care to make sure that the patient has the appropriate management and disposition.

DR. STRIKER:

We're two physicians talking about this, and I imagine the discussion would probably be very different if we had nurse anesthetists involved in the same kind of a discussion. Do you think that physicians should do a better job of intraoperative supervision? Or do you feel like maybe oftentimes the physicians weigh so much on emergence and and induction, and there's opportunity for improvement in perhaps the intraoperative presence?

DR. PERRYMAN:

Well, I think it kind of depends on how well they know each other. If you're doing a case that is a healthy patient and it's not a real difficult surgical case, and they know each other very well, and so the plan is synonymous, then I think that occasionally coming into the operating room, if it's in a long case, is definitely a good idea. But I think that if the patient is higher risk, if the surgery is higher risk, then it's absolutely, extremely important for the anesthesiologist to come by on a regular basis and check to see if there's anything that needs to be discussed or anything that needs to be done differently. That would require more frequent supervision, I would think. Whether the patient's sick or not, they need to take it very seriously that their presence is immediately available, that they're going to check in as it's appropriate.

DR. STRIKER:

Right. There's obviously compliance requirements. And I and I'm talking more in addition to the the sort of minimum compliance requirements.

DR. PERRYMAN:

Right. Yeah.

DR. STRIKER:

Well let's shift a little bit. I want to talk about rural care. Because care in the rural areas certainly present their own unique challenges. And I know one argument against physician led care is that there simply aren't enough anesthesiologists to go around, but particularly in rural areas or other areas that have low resources. What do you think should happen in those settings?

DR. PERRYMAN:

Well, one thing that I think has to happen, as long as we have surgeons supervising the nurse anesthetists--and I think that's that's the most common model probably in the really remote rural hospitals--is that the surgeon really needs to continue to, um, be the person who is supervising the anesthetic and the prescriptions. They have to be immediately available. They have the knowledge base and the decision-making abilities to diagnose and treat their patients. So if an anesthesiologist is unable to be part of the care in that model, a surgeon is the next best alternative to being physically present, as they have the highest medical training to manage their patients. And the other aspect of that is that anesthesiologists are discouraged by the federal government to practice in these rural hospitals because of a financial arrangement that the federal government has. Um, it's called the pass through. They pass through money to eligible rural hospitals to pay for nurse anesthetists, but not for anesthesiologist. And that just it doesn't make sense. There's legislation to to reverse this that needs to be passed. We really need to do that for patient safety and availability.

DR. STRIKER:

You're talking about the particular facet of Medicare where Part A funds are allowed to pass through.

DR. PRERRYMAN:

Yes.

DR. STRIKER:

So that rural hospitals can use those funds for anesthesia services. If, for instance, there's a nurse anesthetist involved but not an anesthesiologist, where part B is solely the funds used to pay for physicians.

DR. PERRYMAN:

Yes. So so, yeah, the hospitals are incentivized by this fund, this pass through payment, to contract with non-physician anesthesia providers because they can get paid more doing that than. And it's my understanding that they they can pay a part time nurse anesthetist a full-time salary with this money, but they can't pay any of it to an anesthesiologist.

DR. STRIKER:

Yeah. If I'm not mistaken, there's a conduit for extra funding for, for hospitals to to pay for anesthesia services that is not available if you're employing or funding an anesthesiologist.

DR. PERRYMAN:

Correct. That's my understanding as well.

DR. STRIKER:

Well, let's talk about the future a little bit. Where do you see our specialty going in the next 10 or 20 years? You've had quite a unique perspective over the years on how anesthesia care has has evolved. Are you optimistic? Concerned? Both?

DR. PERRYMAN:

I … both because I think we need to continue to have well-educated advocates for our specialty, who will go and talk to legislators and explain to them why they shouldn't give independent practice to mid-level providers, explain the safety, and we have to have the energy to do that. We have to keep doing it. As you know, I've been doing this since the late 90s. And I don't think that the nurse anesthetist leaders are going to stop bringing these bills to our state legislatures repeatedly. And I think we just have to keep telling the truth, keep standing up for our patients. And it's a lot of work, but we just have to keep doing it. And we just can't stop. So I think I, you know, I'm optimistic that science and medicine progresses and patient care just keeps getting safer and safer. And I think as long as we can keep the team together and try to help us work in a friendly manner and, we've just got to keep trying to to keep calm, work well together and, uh, foster the Improvement Alliance. And I think everybody can continue to have good careers and good lives and make patient care safer.

DR. STRIKER:

How do you feel that the evolution of the medical and or surgical care of patients in general has affected the roles of anesthesiologists and anesthetists? And I specifically, I guess I'm asking, as the acuity has changed with patients and our ability to provide very intricate, advanced interventions -- anesthetic care has necessarily changed also over the years. Do you feel that the roles necessarily should shift a little, because the acuity and the degree of complexity has has changed?

DR. PERRYMAN:

Well, I think that with really complicated patients with high acuity, I think anesthesiologists should, of course, I'm kind of biased, but I think anesthesiologists should provide their care by themselves. If they're in a practice that allows for mid-levels to be involved in that care, it has to be extremely closely supervised. That has to be the understanding that their participation is not going to be loosely supervised at all, because patients would be too high a risk. And and we do have sicker and sicker patients with more and more complex procedures being done. So I think we have to align those with the proper anesthesiologists and not water down their care. And I don't mean that in a in a negative way. I just mean we have to provide the surgeons involved in those. And the radiologists and procedural are highly trained, and so are the anesthesiologists.

DR. STRIKER:

Well, Dr. Perryman, thank you so much for joining us to share your story and and your very unique perspective on the provision of anesthetic care. And it's always a pleasure to talk to you. And so I thank so much for joining us.

DR. PERRYMAN:

Well thank you, Dr. Striker again. I appreciate all that you do. And thank you for allowing me to talk to you about this.

DR. STRIKER:

Well, absolutely. And to our listeners, thanks for tuning in to this episode of Central Line. Please don't forget to tune in again to our next episode. And in the meantime, take care.

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DR. ALEX ARRIAGE:

Hi, this is Dr. Alex Arriaga with the ASA patient safety editorial board. Teamwork is a hallmark of patient safety. There are some fundamental themes pertaining to teamwork that can enable safer care in the operating room. Communication is relevant for interactions both between anesthesiology colleagues and interprofessional across disciplines. Leadership can include principles such as role, clarity, delegation of tasks, and decision making. Situational awareness is a concept that includes perception of the information in one's environment, comprehension of its relevance, and anticipation of its implications. Safety checklists, which have been designed for both routine and emergency perioperative scenarios, can foster principles of teamwork while also reviewing processes of care. Teamwork is a multifaceted concept that can be leveraged towards the safer care of patients, perioperatively and beyond.

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