Flawed model misrepresents the impact of anesthesiologists to patient safety in the real world.

esthesiologist responded to pages about changes in the patient’s condition or even face-to-face discussions between the anesthesiologist and anesthetist during periodic rounds. Often, initial therapies of physiologic changes can be directed immediately through this type of ongoing communication. Because of this deficiency in the retrospective data set, the statistical model identifies so-called “lapses” where none likely occurred. In addition, we were dismayed that the peer-review process did not identify and correct some major terminology errors and choices in the publication. In the United States, “medical supervision” of anesthesia care by an anesthesiologist differs from “medical direction” of anesthesia care, and the U.S. government defines these differences in federal regulations. The requirements for medical supervision are much less than that for medical direction. Only medical direction requires the anesthesiologist participate in the “most demanding portions” of the anesthesia. Hence using “supervisory ratio” rather than “medical direction ratio” creates needless confusion in discussing and interpreting the results. In addition, as noted above, the medical direction requirements require participation in the “most demanding” parts of care including induction and emergence. The phrase “critical portion” is part of the regulations for teaching residents, but is not applicable to medical direction cases. This further reinforces the fact that the authors created their own definitions for this study. This misuse of these terms creates confusion among readers and the public and is being misinterpreted by some who either do not or choose not to recognize the limitations of this study.* Finally, the word “lapses” is misleading since really what the authors found were “overlaps” based on their self-defined critical portions. They did not demonstrate any lapses in care by the anesthesiologist or the team. They did not study what actually happened; rather they used their broad definitions to determine if potential overlaps would occur. In reality, sometimes a case may be delayed until the anesthesiologist is available to provide safe and quality care; anesthesiologists work as a team both with anesthesia providers in the specific OR but also among themselves to make sure each patient receiving medically directed anesthesia has an anesthesiologistpersonallyparticipate inalldemandingportionsof the patient’s care.