I have just concluded five years of chairing the ASA Committee on Anesthesia Care Team (CACT), a highlight of my time as an active ASA member. A group of passionate, motivated, and knowledgeable individuals, the CACT is committed to the highest quality of perioperative medicine and anesthesia practice. Reflecting on recent work of the CACT, there are numerous anesthesia-related political issues in the United States, ranging from scope of practice to reimbursement. Negative sentiments are myriad, including the contention that physicians do not bring value nor increase safety. We also often hear from advanced practice providers that “all we want to do is practice to the full extent of our license.” The future will reveal to us the benefits or concerns with any health care professional practicing to the full limits of their respective licenses.

The Centers for Medicare & Medicaid Services (CMS) is clear in its definitions of who qualifies as an anesthesia professional and what constitutes medical direction. Less clear is what constitutes medical supervision. The terms are confusing. Retrospective CMS data suggest that approximately one-third of anesthetics in the U.S. are physician-only (modifier AA), one-third are anesthesia care team (modifiers QK, QY), and the remaining third are CRNAs without physician direction (modifier QZ) (asamonitor.pub/47jXCda). A lack of clarity in the definition of QZ is illuminating. Does 100% of QZ coding truly reflect zero physician involvement? CMS data tell us that anesthesiologists are involved in two-thirds of anesthetics (asamonitor.pub/3dpa9Wz). Certainly, there is a percentage of billing with physician involvement that is not designated on the medical record, insurance submissions, or other documentation. It is imperative for our specialty to reflect accurately the extent of physician involvement for the purposes of billing, evaluating quality and safety, and optimizing patient outcomes.

Frankly, our system is flawed. Modifiers should be accurate. If anesthesiologists are truly not involved then, yes, use QZ. If, however, we have some involvement, then a modifier should reflect this, and the physician anesthesiologist of record should have his or her name in the chart. When physicians are involved, present, or available, but not necessarily supervising, perhaps there should be a new, less confusing modifier, “QI” – physician-involved care.

Following the theme of this month’s ASA Monitor, let us turn from the U.S. to the realities of perioperative care elsewhere on our planet. We are fortunate to have some of the most prestigious, sought-after health care institutions in the world. However, U.S. metrics for quality, safety, morbidity, and mortality are not reassuring, revealing a complex picture of health that extends beyond anesthesia. Perioperative care is an integral component of global health and should be examined to ensure the U.S. is not also ranked below other countries in this domain.

In February 2019, the Anesthesia Patient Safety Foundation (APSF) Newsletter ran a lead article titled “International Standards for a Safe Practice of Anesthesia” (Anesth Analg 2018;126:2047-55). In step with the World Health Organization, it recommends a standard: “wherever and whenever possible anesthesia care should be directed by a physician anesthesiologist.” Based upon this article, one of two major APSF supporters withdrew their support. The APSF, founded in 1985 as a nonprofit corporation, has the vision that “no patient shall be harmed by anesthesia.” Its quarterly newsletter is the largest circulating anesthesia publication in the world. It is perplexing why support would be withdrawn for an organization whose goal is patient safety, especially considering the makeup of the APSF Board of Directors, which includes anesthesia professionals of various training backgrounds, including physicians, certified anesthesiologist assistants, and nurse anesthetists.

The World Federation of Societies of Anaesthesiologists (WFSA) provides an interactive world map with a perspective of anesthesia practice across the globe (Figure, with QR code). What do Canada, Mexico, Brazil, Australia, China, India, Germany, Japan, Israel, the United Kingdom, and others have in common? Physicians are listed as the only medical professionals providing anesthesia care to patients! In some countries, it is illegal for “nonphysicians” to provide anesthesia care (BMC Anesthesiol 2022;22:250; asamonitor.pub/30bffPZ). Quantitative data suggest that much of the world’s population receives anesthesia care solely from physicians. However, in some countries there are associated professionals with varying levels of official and unofficial training, such as assistants and nurses. In many places, these individuals do not provide care without an anesthesiologist in continuous attendance (Korean Med Sci 2016;31:131-8). Several countries have mid-level professionals, though the extent of training and independence are unclear. The survey data presented by the WFSA workforce map is from 2015-2016 and strictly quantitative. What is less clear is how anesthesia is practiced in these countries, as there is no narrative or information on practice roles, independence, or training. Further, the data are incomplete and now outdated, pending an update through 2021.


I do not propose that we change anesthesia care in the U.S. to reflect the countries mentioned above. Our system is a team-based model involving highly trained physician anesthesiologists, residents, fellows, nurse anesthetists, and certified anesthesiologist assistants. However, patients, ASA, and much of the world believe anesthesia care should involve anesthesiologists, a sentiment paraphrased as “Anesthesiology is the Practice of Medicine.” Although possible, it is unlikely that legislators in other countries are being asked to adjudicate or eliminate patients’ access to physician-led anesthesia care.

In the U.S., there is a continuous subcurrent of opinion that patients do not need anesthesiologists, going so far as to suggest that student nurse anesthetists can function alone as qualified practitioners. Has anesthesia become sufficiently safe that people believe almost anyone can perform its requisite functions? Perhaps these sentiments arise because our day-to-day tasks, procedures, and skills are thought to be easily taught and easily mastered. Is the formative process and the rite of passage of a premedical education, medical school, and residency necessary for anesthesia and, by extension, other medical specialties?

We should reflect on how our specialty is represented in the world, including countries where there are extreme shortages of all anesthesia professionals. Whereas we have an impressive array of anesthesia professionals in the U.S., we must continue to educate our legislators as to our years of education, hours of training, subspecialty training, enhanced safety and quality metrics, and cost savings. We should mention that, as physicians, we do not practice to the full extent of our “physician license.” Additionally, we should educate others regarding the global picture of physician-led anesthesiology. It is possible that a global perspective might encourage more support for integrated, physician-led care. Further, physician-led care must be advocated for in other countries, underscoring that the involvement of highly trained nurses and assistants enhances care, especially as global demands for perioperative care continue to increase.

In closing, I return to the state of affairs in the U.S. with food for thought. All of us in health care are familiar with the amalgamated term “provider.” Professionals in other fields would never accept such a designation. In medicine, despite a significantly greater breadth and depth of knowledge and training, we seem to have acquiesced to our designation as providers. In our specialty, we have progressed from “anesthesia will come to talk to you” to “your anesthesia provider will be coming to speak to you.” For generations, patients have known what the title “doctor” means. They may be unaware of the details of our education and training, yet it is clear to them and their families what a doctor’s role is; they know that doctors are the most highly trained health professionals. Physicians are the best trained to make life-and-death decisions for patients and their families.

Soon, every advanced practice professional may be granted diplomas, titled as “doctor.” In the coming years, the public, our patients, and our legislators will grow more confused and troubled, with everyone being labeled “a doctor.” It is likely this confusion could be the stimulus for patients, even legislators, to request and demand physician-led care for themselves and their families. We hope to see all of this play out in the safest and best outcomes for patients in the U.S. and across the oceans as well.