Money, yes. Smart...

February 2005 -- This month's issue of Smart Money ("The Wall Street Journal Magazine of Personal Business") includes an item by Erika Rasmusson Janes called "10 Things Your Plastic Surgeon Won't Tell You," which includes practical tips for getting aesthetic plastic surgery. Item number 4, which addresses anesthesia and appears to rely principally on "Park Avenue Plastic Surgeon" Z. Paul Lorenc (pictured below), denigrates the work of nurse-anesthetists. It effectively tells readers they should use anesthesiologists, without explicitly saying so. However, a large body of peer-reviewed research shows that the nation's masters-prepared certified nurse anesthetists provide care that is equal to or better than that of anesthesiologists. The magazine's publication of scientifically unfounded assertions without any response from a nurse anesthetist is irresponsible.

This piece is one of a continuing series of "10 Things..." features in Smart Money. Item number 4 is entitled "It's the anesthesia you need to worry about," and it reads in part:

Ask whether your surgeon uses a nurse-anesthetist or a board-certified anesthesiologist. "An anesthesiologist is a fully trained professional who is dedicated to that patient and doesn't have to be supervised," Lorenc says. But in many states, nurse anesthetists do require supervision, and oftentimes your plastic surgeon will be the one doing the supervising.

That's not to say nurse-anesthetists aren't competent, but it does mean you should ask additional questions--like what the anesthetist's experience is with outpatient plastic surgery. If your physician uses nurse-anesthetists and you prefer a board-certified anesthesiologist, ask if it's possible to have one.

Dr. Lorenc and the piece itself make an unusual effort not to offend certified registered nurse anesthetists (CRNA's), even as they wrongly suggest that the use of CRNA's is unsafe. Rather than simply saying that, as Dr. Lorenc's colleague R. Patrick Abergel was quoted as doing in the June 2004 Vogue, Lorenc focuses on what's good about anesthesiologists. Of course, the obvious implications are that CRNA's are not "fully trained professionals," not "dedicated" to their patients, and unable to function autonomously. All of those implications are provably wrong, as even a quick consultation with a CRNA or the American Association of Nurse Anesthetists (AANA) would have confirmed. Actually, the piece is full of cites to plastic surgery-related web sites, but it seems not to have occurred to the writer to consult the AANA site, perhaps because she simply assumed that surgeons would tell her all there is to know about the care of surgery patients. That faith was misplaced. A magazine so ostensibly focused on consumer savvy might have asked itself what financial agendas could be in play for those who provide it with expert advice, and whether what it was hearing was supported by reliable scientific data, or whether it had more to do with bias, or a particular business model. Exclusive use of anesthesiologists would appear to be a good vehicle for upselling in the more elite sectors of the plastic surgery industry. (Dr. Lorenc's plastic surgery business is heavily promoted in the mass media, as it is being promoted in the Smart Money article.)

In fact, published studies have shown that the care of nurse anesthetists is at least as good as that of anesthesiologists, and this piece offers no scientific support for the idea that nurse anesthetists are less qualified. Many such studies are collected in the AANA"s research database. Nurse anesthetists are highly skilled professionals with 7-8 years of university education, culminating in master's degrees from accredited nurse anesthesia programs, and many have Ph.D.'s. They provide vital anesthesia services to thousands of surgical patients daily, especially in more remote areas with insufficient business potential to attract anesthesiologists. In fact, CRNA's provide the majority of office anesthesia care--including the majority of plastic surgery office anesthesia care--in the United States.

Taking its cue from Dr. Lorenc, the piece itself is quick to assure CRNA's that it's not saying they "aren't competent," but it's obviously saying they're less competent. Likewise, the last line clearly encourages readers to express a preference for anesthesiologists, though it avoids actually saying that. It's interesting that the piece singles out CRNA's--certified anesthesia professionals--for disparagement, but not plastic surgeons who try to handle the anesthesia themselves (a leading cause of patient injury in office settings), or the many anesthesiologists who are not board-certified.

The assertion that CRNA's "require supervision" in "many states" is more complex, and the piece does not take the trouble to explain it. Plastic surgeons are of course not professionally qualified to "supervise" a CRNA's provision of anesthesia, any more than they are to brand an entire class of masters-prepared nurses who save lives as less than "fully trained professionals." Most states do still follow Medicare reimbursement rules that technically require "supervision" of nurse anesthetists by a physician. But since states were given the chance to opt out of this requirement in 2001, 12 have done so. In making this significant change to its rules, Medicare acknowledged CRNAs' outstanding safety record and high standard of care. The federal program's decision has been justified. Since the rule change, the AANA reports that not a single anesthesia patient death or injury has been shown to be related to the removal of the supervision rule in the states that have opted out. In reality, the anesthesia education and training of CRNA's is just as extensive and rigorous as that of anesthesiologists. Both CRNA's and anesthesiologists work closely and collaboratively with surgeons to ensure the best care for patients, using the same anesthesia techniques and standards of care.

In general, though the media sometimes publishes statements questioning the quality of care provided by advanced practice nurses (APRNs) such as nurse anesthetists, numerous studies have found that APRNs provide care that is equal to or better than that of physicians. The FAQ section of the Center's web site contains a growing list of studies comparing the quality of care delivered by these two types of health care professionals.

Smart Money should have consulted a nurse anesthetist or the AANA for the facts. The magazine and Dr. Lorenc owe nurse-anesthetists, who number 30,000 in the United States alone, an apology. The Center urges all supporters to seek one, and to speak out about the critical role nurse anesthetists play in modern health care.

May 2006 -- We have closed this campaign after 15 months. While neither Paul Lorenc nor Smart Money replied to us, we have little doubt that they took notice of the more than 65 letters like the one below that we and our supporters sent. We have not heard that either one of them has since repeated inaccurate statements about the qualifications of advanced practice nurses.

Dear Z. Paul Lorenc and Smart Money editors:

I am writing to express my grave concern about inaccurate and harmful statements about nurse anesthetists in the February 2005 edition of Smart Money magazine. The article, by Erika Rasmusson Janes called "10 Things Your Plastic Surgeon Won't Tell You," includes practical tips for getting aesthetic plastic surgery. Item number 4, which addresses anesthesia and appears to rely principally on "Park Avenue Plastic Surgeon" Z. Paul Lorenc, denigrates the work of nurse-anesthetists, effectively telling readers they should use anesthesiologists, while not quite having the courage to say so. A large body of peer-reviewed scientific research shows that nurse anesthetists provide care that is equal to or better than that of anesthesiologists. The magazine's publication of scientifically unfounded assertions without any response from a nurse anesthetist is irresponsible.

This item reads in part:

Ask whether your surgeon uses a nurse-anesthetist or a board-certified anesthesiologist. 'An anesthesiologist is a fully trained professional who is dedicated to that patient and doesn't have to be supervised,' Lorenc says. But in many states, nurse anesthetists do require supervision, and oftentimes your plastic surgeon will be the one doing the supervising.'

'That's not to say nurse-anesthetists aren't competent, but it does mean you should ask additional questions--like what the anesthetist's experience is with outpatient plastic surgery. If your physician uses nurse-anesthetists and you prefer a board-certified anesthesiologist, ask if it's possible to have one.'

Dr. Lorenc and the piece itself are making an unusual effort not to offend nurse-anesthetists. Rather than simply saying that the use of certified registered nurse anesthetists (CRNA's) is unsafe, he focuses on what's good about anesthesiologists. Of course, the obvious implications are that CRNA's are not "fully trained professionals," not "dedicated" to their patients, and unable to function autonomously. All of those implications are provably wrong, as even a quick consultation with a CRNA or the American Association of Nurse Anesthetists (AANA) would have confirmed. Actually, the piece is full of cites to plastic surgery-related web sites, but it seems not to have occurred to the writer to consult the AANA site, perhaps because she simply assumed that surgeons would tell her all there is to know about the care of surgery patients. That faith was misplaced. A magazine so ostensibly focused on consumer savvy might have asked itself what financial agendas could be in play for those who provide it with expert advice, and whether what it was hearing was supported by reliable scientific data, or whether it had more to do with bias, or a particular business model. Exclusive use of anesthesiologists would appear to be a good vehicle for upselling in the more elite sectors of the plastic surgery industry. (Dr. Lorenc's plastic surgery business is heavily promoted in the mass media, as it is being promoted in this article.)

Taking its cue from Dr. Lorenc, the piece itself is quick to assure CRNA's that it's not saying they "aren't competent," but it's obviously saying they're less competent. Likewise, the last line clearly encourages readers to express a preference for anesthesiologists, though it avoids actually saying that. It's interesting that the piece singles out CRNA's--certified anesthesia professionals--for criticism, but not plastic surgeons who try to handle the anesthesia themselves, or anesthesiologists who are not board-certified. Indeed, it does not appear to have consulted anesthesiologists, perhaps (again) because the surgeons know everything. But the piece is not spreading disinformation about the anesthesiologists.

In general, though the media sometimes publishes statements questioning the quality of care provided by advanced practice nurses (APRNs) such as nurse anesthetists, numerous studies have found that APRNs provide care that is equal to or better than that of physicians. The FAQ section of the Center for Nursing Advocacy's web site contains a growing list of studies comparing the quality of care delivered by these two types of health care professionals. <www.truthaboutnursing.org/faq/apn_md_relative_merits.html>

Smart Money should have consulted a nurse anesthetist or the AANA for the facts. The magazine and Dr. Lorenc owe nurse-anesthetists, who number 30,000 in the United States alone, an apology. I also urge you to consult nurse experts on any future health-related articles, to help prevent problems such as this one. It is essential that the public learn the truth about the critical role nurse anesthetists play in modern health care.