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The Anesthesia Dilemma

The Anesthesia Dilemma

Picture of Jan  Mannino

There is no single topic in health care that involves as much emotion as who should do anesthesia. It is the probably the only profession in healthcare where there are two licensed providers, with different educational backgrounds who can perform exactly the same functions. Medical Anesthesiologists and Certified Registered Nurse Anesthetists (CRNA) both can do exactly the same functions in the operating rooms. Anesthesia Assistants are also another group of providers, but unlike CRNAs must work in a practice that is supervised by anesthesiologists.

In the current health care economic environment, looking for a provider that provides a similiar service as a physician at a lower cost is very attractive option. Besides the econocmic issue, quality of care delivery is an equal component of the equation. In anesthesia services, cheaper must not be the prime motivator, if there are quality issues.

The purpose of my blog is to examine the history of both professions, the legal issues and ecomomic components that will be a guiding force in the future of health care in America. I will be upfront and admit my biases are towards CRNAs and their indpendent practice. While it is interesting to review history, to hear the stories, to read the studies, the story is being told every day in the surgical and diagnostic suites around the country. I have worked in those facilities for many years and have seen first hand the actual practices, how CRNAs are considered inferior practitioners until late evening and night, where they all of the sudden become intelligent enough to administer anesthesia for major trauma cases, difficult obstetrical cases and assist in the Emergency Department and Critical Care Units.

Operating rooms are inner sanctums, rarely seen in other settings. This blog with open those doors with a reality most hospital administrators, surgeons and hands on clinicians don't want the public to see or experience. If you think you know about surgery because you have watched it on TV or the movies, you have been fooled. Stay with me, ask questions, listen to the answers and be prepared to be enlightened.


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This conflict reminds me of the early days of midwifery, when docs screamed blue murder as trained midwives threatened their turf. Ditto for nurse practitioners - just read on any given day for a dose of sputtering outrage that "these people" are allowed to work in stand-alone well clinics.

It seems that any expanded scope of practice threatens to step on somebody's toes.

Picture of Marni Hancock

I agree that CRNAs are often preferable to anesthesiologists and for a number of reasons.  And, everywhere in nursing, you would be amazed to discover how competent nurses become after about 5 pm and until about 8 am and on weekends and holidays. However, there are some underlying issues I think might be considered.  My understanding is that medical students now start focusing their planned practice role before they graduate from medical school and find it expensive and difficult to change practice areas.  Most nurses, on the other hand, graduate as "generalists" and nurses who want to become CRNAs usually have to get 2 years of experience in critical care/emergency room care prior to being accepted to the CRNA program.  Their education, while expensive, is not nearly as expensive as medical school and the specialty training that follows.  I believe (and would love to see research done) that CRNAs are much less likely to feel trapped in their roles and are less likely to experience "burnout" in their roles.  Add that their primary education in nursing focused on understanding and caring about patients and not so much on diagnosing, treating, and curing the diseases or injuries patients have, and you have a practitioner with a somewhat different focus that what most physicians appear to have.

I think that all of these factors combined explain a lot of the differences in focus and care provided by CRNAs compared to anesthesiologists.

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Dr Scot Foster, CRNA, past President of the American Association of Nurse Anesthetists: "Ours is a role of physiologic support and monitoring and intervention. Ours is not a diagnostic and cure paradigm at all."

Picture of David Martin

Let me share a few observations after 20+ years of practice as a physician/anesthesiologist. First, you could probably train a chimp to provide anesthetic care in most cases. Admit it, it just isn't that complicated! And while this sounds denigrating to both MDs and CRNAs, we should applaud ourselves for achieving Sigma 6 safety in what was a dangerous specialty not long ago. Approaching airline safety levels (for ASA I and II) patients has been made possible largely by introducing the use of routine protocols to much of our trade, which does make our profession largely trainable and frequently, I must confess, "cookbook".

For patients that give us that 1% of sheer terror and whose problems can't be found in the index of a textbook, I believe that judgment and teamwork allow us to think "outside the box" more effectively and solve difficult problems more readily than an encyclopedic base of knowledge. These characteristics can be cultivated by physicians and nurses. Both are credible players on this field.

That said, let me share a few empirical observations, having worked in several large hospital organizations staffed by MD and CRNA anesthetists. First, there are many CRNAs I would choose for my own care in lieu of many of our physicians; both are capable of rising to the top. Second, MDs (with many exceptions) are more likely to practice evidence-based anesthesiology, while CRNAs (again, many exceptions) generally rely on empiric experience and the bias that was introduced in their training. This observation is shared by our best CRNAs. This has to change if CRNAs want to sidestep their Rodney Dangerfield designation in the OR. I wonder if Ms. Mannino might comment on this? Is learning how to evolve and mature in practice part of CRNA training? I just don't see enough of it.

That should stir the pot enough for now. Before I close, I have to chime in on Ms. Hancock's comments. Yes, there is unquestionably a double standard based on the clock and calendar. And this practice needs to stop! Let us all go the table and decide what cases do require MDs. Personally, I believe the list is short. Failure to attend them at 2 AM should have harsh consequences. If doctors want to maintain their commanding role in this profession, they need to act more responsibly.


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