To the Editor:—

The first casualty of any war is truth. After many months and hearing through secondary sources and vested interests what the Silber et al.  1study did or did not find, it is published in full, and anesthesiologists are free to distinguish truth from fiction for themselves. Silber et al.  1conclude that with medical direction of certified registered nurse anesthetists (CRNAs) by anesthesiologists versus  nonanesthesiologist direction of CRNAs, there are 2.5 excess deaths per 1,000 patients and 6.9 excess failures to rescue (deaths) per 1,000 patients. However, by the nature of its design, this study could not and does not address the key issue: can CRNAs practice independently? In fact, the negative outcomes in this retrospective study may be related to the medical direction of nonanesthesiologists and may not be related in any way to the practice of CRNAs per se . This is not as far fetched as one at first may think. Many surgeons, after many years of long, arduous, highly specialized training, are far removed from physiologic concepts central to anesthetic and supportive care in general. Who amongst us has not heard a surgical colleague express a forceful opinion regarding anesthesia practice that clearly violates the standards of contemporary anesthetic care? I also suspect that when supervising a CRNA, many surgeons still believe in the concept of “surgeon as captain of the ship.” These factors could lead to injudicious directives on the part of the surgeon to the CRNA during critical events. Therefore, the negative outcomes as reported by Silber et al.  1might be attributed wholly to the supervisor (surgeon) rather than the person being supervised (CRNA). The hypothesis that positive outcomes (or at least neutral outcomes) might result from the independent practice of CRNAs is in no way ruled out. Silber et al.  1freely admit as much when they state, “Future work will be needed to determine whether the mortality differences in this report were caused by differences in the quality of direction amongst providers, the presence or absences of direction itself [italics added], or a combination of these effects.”1That is why the proposed national study of comparative anesthesia outcomes is critically important.

Loyola University Stritch School of Medicine, Edward Hines Jr. Veterans Hospital, Hines, Illinois.

Silber HS, Kennedy SK, Evan-Shoshan O, Chen W, Koziol LF, Showan AM, Longnecker DE: Anesthesiologist direction and patient outcomes. A nesthesiology 2000; 93: 152–63