| February 28, 2012
The nurse-anesthetist is starting a patient on anesthesia for an imminent surgical procedure. As the patient starts to fade, he sees a figure walking in the room in surgical scrubs. He thinks this person is the surgeon but then realizes that it's the bachelor’s level therapist who screened him for psychiatric issues prior to surgery. "Wait," he cries out, "you're a therapist, not a surgeon. There's no research to demonstrate that you can perform surgery!" The therapist lowers his mask and smiles. "That's true, but there's no research to say that I can't either."
This scenario is the basis of a nightmare with many specialties of medicine, but for some reason, addiction is treated by many who have no significant healthcare qualifications. And there has been no research demonstrating that these non-physicians have the necessary skills to treat a chronic medical illness. Even our research often utilizes a comparison group in which patients receive "treatment" from non-physicians. If Drug A is superior to Treatment as provided by midlevel clinicians, then Drug A is approved. No one bothers to demonstrate that Drug A is better than Treatment as provided by physicians. Is it because they cannot? Or is it because the perception is that there is no difference?
But of course as our nightmare therapist points out, there is no research to say that physician-provided treatment is any more effective than midlevel clinician treatment. Or that there isn't a wide range of quality among physicians themselves. Much depends on what question is asked, and how the question is worded. Let's say I ask, "Do anesthesiologists and nurse-anesthetists have equivalent rates of negative outcomes?" The answer is that, in fact, they do. So at first glance one might say there's no difference. But then let's ask a different question: "Given an emergent situation during a surgery, do anesthesiologists and nurse-anesthetists have the same rate of negative outcomes?" That comparison provides a very different outcome.
As we say in the airplane, nearly all pilots can get you from Point A to Point B safely. But throw in bad weather, an in-flight mechanical failure, and a bird strike and only the best pilot will successfully land the plane. The problem in life is that we never know if any one patient has these problems. From a population standpoint, we know most do not, but from an individual standpoint - as seen by any one patient - you want to be in the best hands at all times. I want the best pilot, the best physician, in any circumstance because I don't know if on this particular day, my patient will come up with a losing hand.
So who is the best? Lou Baxter, Penny Mills, and I met with NIAAA today. We'll share more about that meeting in future blogs, but I was particularly interested to hear of research funding being made available for comparative efficacy trials. We can finally begin to address the question as to which set of initials should be carrying out which role within addiction treatment. If in fact we're all the same, then we need to markedly reduce the educational burden on physicians entering this field - we would be shown to be overeducated for the given job. And if we're not the same, then we could speak out for our patients to ensure that they receive appropriate care for their illness just as we would expect given any other chronic medical condition.