The Local, Global Perspective

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We commend Lipnick et al1 for bringing to light the need to reframe the debate between anesthesiologists and nonphysician anesthesia providers. Lipnick et al1 argue that there must be “productive dialogue” about task sharing because “a universal model based on service provision by a single-handed anesthesiologist is untenable.”1 Further, they note the “education and clinical training of all anesthesia providers should be overseen in an integrated fashion.” While we agree on both fronts, we would like to point out that anesthesiologists found themselves in similar circumstances more than 60 years ago.
During World War II, the military and civilian medical sectors could not provide necessary numbers of trained anesthesiologists. In fact, most anesthesia providers were female nurse anesthetists barred from the draft. In response, the individuals responsible for wartime education in anesthesia displayed adaptability and ingenuity by exploring and using all the resources available. For example, Colonel Tovell recommended that “medical officers not assigned to anesthesia should crosstrain” to provider services “in times of high demand.” On the front lines, anesthesiologists quickly learned that regional anesthetics, safely monitored by a nonanesthesiologist, freed them to care for more complicated patients. Here, the polarization presented by Lipnick et al1 already existed. Anesthesiologists used “nurses and enlisted men as ‘robots’ to do as I told them.”2 It is ironic that the same ingenuity that drove military leaders to create an educational curriculum that ensured safe anesthesia care did not extend to nonanesthesiologists.
On a more local level, John Abajian founded the Division of Anesthesiology at the University of Vermont in December 1939, although it did not truly exist until he hired his first nurse anesthetist, Betty Wells, in 1941.3 After the war, Wells trained many new members of the early division, and that respectful dialogue still continues between anesthesiologists and nonphysician anesthesia providers. Today, the department annually bestows the Betty Wells Award on the nonphysician anesthesia provider who best exemplifies her teaching principles as they relate to certified registered nurse anesthetist students, anesthesiology assistant students, and medical students. In retrospect, the culture of the department today is a legacy of clinical, educational, and administrative task sharing.
In short, effective task sharing enables anesthesiologists and nonphysician anesthesia providers to be stewards of safe, effective anesthesia care. Today, this idea of task sharing, or resource optimization, is not new to health care delivery. Govindarajan et al4 have argued that the study of health care systems outside of the United States affords the opportunity to understand the waste, redundancy, and inefficiencies of the current American system. We can dig into our domestic trenches despite the global discrepancies in surgical and anesthesia care. Or we can build a better system. Perhaps it starts with task sharing. Or maybe it starts with the simple recognition that whether one is an anesthesiologist or a nonphysician anesthesia provider, the patients are what matter most.
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