Monday, August 23, 2010

ASA President Defends Anesthesiologists, Feebly

The American Society of Anesthesiologists is losing a public relations war with the nurse anesthetists.  There was that recent AANA sponsored study splashed across the pages of that claimed the care received by MDAs and CRNAs are equivalent.  Then there is this study in the Journal of Nursing Economics that claims the care provided by CRNAs is 25% cheaper than anesthesiologists without affecting the quality. Oy vey! Alexander Hannenberg, MD, president of the ASA, has been a pretty busy guy lately, putting out all these PR fires smoldering around the Society.  He was quickly trotted out to dispute the findings of this latest paper.  But upon reading his defense of anesthesiologists, it is obvious he has little substance to work with.  It reads more like a he said/she said argument.  His line of reasoning wouldn't pass muster in a high school debate class.

In this interview he makes seven points about MDAs vs. CRNAs.  I won't reprint his arguments in their entirety here but you can read his interview in Becker's ASC Review.  I'll just go down the line and give my two cents about why his assertions are weak and almost indefensible.

1. Scope of services provided by MDAs and CRNAs are not equivalent.  Maybe not completely equivalent but in reality they are quite close.  Critical Care Medicine is one field where CRNAs don't practice.  But few anesthesiologists practice CCM either.  Out of around 40,000 anesthesiologists in this country, the American Society of Critical Care Anesthesiologists only counts 563 members.  And that includes resident and medical student memberships.  So for all intents and purposes, MDA and CRNA practice parameters are practically equivalent.  What about Pain Medicine?  Here the ASA is running around the country trying to legislate pain procedures out of CRNAs' hands.  If not for legal obstacles many CRNAs would be in procedure rooms right now doing blocks just like MDAs.

2. Comparison of outcomes invalid. It is true that studies show MDAs take care of sicker patients than CRNAs.  That was also found in the WSJ article.  But the reason for that is most rural hospitals only have CRNAs staffing the ORs.  These small hospitals typically handle more routine cases.  Any complicated cases are transferred to urban tertiary care facilities.  It will be impossible to fully equalize the case complexities between doctors and nurses. Good luck trying to attract anesthesiologists to 75 bed hospitals in the middle of Podunk City, Middle of Nowhere, U.S.A. 

3. CRNAs rarely go "solo" when administering anesthesia. This argument is not going to last much longer.  More and more states are deciding to opt out of Medicare's requirement to have physician supervision over nurse anesthetists.  Regardless, taking care of a surgical patient is a team approach, or at least that's the way it was always taught to me in anesthesiology residency.  Even anesthesiologists don't always decide on the anesthesia "solo". We consult with surgeons when there is a complicated or unusual the patient. Together as a team we decide on the anesthesia that will provide the best outcome for the patient. No prima donnas in front of or behind the surgical drapes.

4. Use of CRNAs as solo providers could cost more for Medicare patients. Here Dr. Hannenberg's argument is particularly specious.  He claims that CRNAs would actually cost more because they will order more medical consults than MDAs to "assess co-existing medical conditions." Really Dr. Hannenberg? I've ordered plenty of consultations myself if I felt the patient needed it to get through an operation safely.  Besides, many surgeons prefer to work with CRNAs precisely because they are less likely to delay a case for further medical workup, for better or worse.

5. CRNA and physician compensation are not an apple-to-apple comparison. This is actually a sad indictment against anesthesiologists but alas also true.  A hospital will have to pay nurse anesthetists overtime to work nights and weekends regardless of the number of cases performed, potentially raising their costs.  We smart anesthesiologists are so smug in our superiority that we don't mind sitting around in an uncomfortable doctor's lounge, away from our families, uncompensated, wondering when our next meal ticket will arrive in the emergency room.  There goes another sleepless night on call in the hospital only billing for an appendectomy and a couple of epidurals.

6. Study is unsubstantiated, inaccurate and questionable. Dr. Hannenberg cites a CDC study in 1980 that said comparisons between CRNAs and MDAs are unachievable since the rates of mortality and morbidity from anesthesia are so low.  And they are lower now thirty years later.  Well, it can be argued that if the difference in M&M is so low between the two professions, the nurses must be doing something right.

7. Patients prefer physician anesthesiologists. This maybe true, if the costs were the same.  But how many patients have been surprised by a bill from an anesthesiologist who was not in their insurance network and subsequently disputed or refused the charges? Do you think these people would feel more satisfaction with their hospital and surgeon if they got no anesthesia bill at all because the CRNA administering the anesthesia was an employee of the hospital and thus wouldn't charge the patient separately? Where is the study that shows patients prefer paying extra for an anesthesiologist or anesthesiologist-supervised CRNA vs. a free solo or surgeon-supervised CRNA?  (Free meaning their insurance company pays for it.) Are we afraid to find that people would not want to pay more money to be anesthetized by an MDA or MDA-supervised CRNA? And how much more would patients be willing to pay to have an anesthesiologist instead of a CRNA give the anesthetic?  $1000? $100? $10? Of course it's easy for people to tell researchers they want anesthesiologists present or nearby when the anesthetic is given.  But when they have to reach deep into their own pockets for the privilege I'm willing to bet their stories will change pretty quickly. That type of study involving real money will need to be conducted to prove we are indeed preferred over CRNAs.

As a practicing anesthesiologist, and a proud member of the ASA who contributes to ASAPAC every year, it pains me to have to write these words.  And it really isn't Dr. Hannenberg's fault that his arguments are so anemic.  We anesthesiologists are so busy in our ivory towers trying to understand the molecular basis of lung ventilation in the name of patient safety that we have failed to see the soul of anesthesiology is being hijacked by the nurses.  While the AANA is cranking out multiple papers per year on why they are at least equivalent to MDAs for less cost, we haven't produced a study demonstrating the value of anesthesiologists in today's health care environment.  The nurses only need to prove they provide care as well as doctors to have an advantage, because if all else being equal, the deciding factor will be cost, their ultimate trump card.  If that situation should come to pass, the only way we anesthesiologists can stay gainfully employed is if we lower ourselves to an equivalent salary.  That will indeed be a sad day for anesthesiology.


  1. I agree with most of your observations, but I am disappointed in your conclusions. Anesthesiology, by definition is the study of anesthesia and therefore the soul of anesthesiology. Rather than lament the "ivory towers" acknowledge and appreciate the value they add.

  2. As a practicing CV Anesthesiologist who is double boarded - the growing autonomy and arrogance of CRNAs is absurd - not to mention downright clinically scary. I have never concerned myself with nurses replacing me - Why? Because they can't....

    Anesthesia is both an art and a science. And while CRNAs can be trained as technicians - it is the art of anesthesia in which they simply do not have the background knowledge to apply - The old adage - if you're thinking sux - you better be giving it - comes to mind...

    Having previously supervised CRNAs who fail to recognize when the SHTF - I now do all my own cases - and there is no shortage of work - nor have I taken a pay cut.

    CRNAs as pain management specialists? Seriously? Perhaps if they stuck with Tylenol administration I'd be comfortable....

    This is an old argument. If CRNAs want to be anesthesiologists - go to med school, residency, fellowship and do the work. There are no shortcuts.

  3. Tess, anesthesiologists can bloviate all we want. We can all tell tales about the scarily incompetent CRNA that we once had to rescue to keep a patient from dying a horrible tragically unnecessary death. But until there are actual studies to prove we are clinically superior, the AANA will continue to make inroads into the OR, one room and one hospital at a time. Anecdotal evidence will not cut it with the people who pay our bills.
    And yes the CRNAs want to do pain procedures. Read past issues of the ASA Newsletter They may not be able to make the diagnosis, which is still MD territory, but they are hell bent on doing the procedures, which is where the big bucks are.

  4. I am a practicing CRNA. It gives me hope to see that there are some open minded anesthesiologists. This "war" between our professions was indeed started by the touting the superiority in outcome by anesthesiologists versus CRNA's. I do cases every day. How many docs can say that? Certainly not the majority. If you cover CRNA's, this is not doing anesthesia. You do not deal with the minute to minute decisions. You can say they call me when the S''t hits the fan, but how many practicing docs can honestly say that they have never been in a room and dealt with the fan? It is the reason we are there, as guardians. As a practioner, I deal with changes, patterns and intuitions to prevent problems from happening. But sometimes things happen that are beyond anyone's control. If there is an MDA cover, I call them for help. No doc cover....CRNA available, works for me and the patient. Help is help....even anesthesiologists get into situations where they just don't have enough hands. It's always brought up that someone had to "rescue" an incompetent CRNA. I don't doubt that there are some out there. But also, tell the other side...The MDA that hasn't been in a room (doing cases, not breaks) for a whole bunch of years. Who do you want at the head of your bed, someone that does anesthesia every day or one that's in there occasionally. If I sound frustrated, I am. Does it mean I feel superior to or dislike anesthesia docs? No. I respect the fact that you have spent a lot of time in school and training. I do dislike the arrogance of many of you, the lack of mutual respect for what we do, and the point that you do not back up your scare statements to the public with facts. You have forced the AANA into having studies done to prove our assertions. A foundation of good science. I currently work for a anesthesiologist group that I have been with for fifteen years. We have a mutual respect relationship, so I know this is possible. It's time we quit this nonsense and took the focus off of one another and put it where it should be.....the betterment of our patients.

  5. To ZMD - haha - clinically superior? In what aspect? Bedpan delivery? I will give you that. Too funny.

    Regardless - your statement - "They may not be able to make the diagnosis, which is still MD territory, but they are hell bent on doing the procedures, which is where the big bucks are." BIG BUCKS - the driving force behind nurses desire to play doctor. Go to school, get the credentials, then you won't have to pretend.

  6. That's true, we can sit in the lounge and watch to see how soon the first off can leave(just like a real anesthesiologist!!)

  7. @ CLF, CRNA - No idea where you work or with whom - but you're experiences expressed certainly don't mirror my practices or those of the colleagues I work with... Frankly there are bad apples in every occupation/profession. If you had been able to get through med school/residency/fellowship - you would have. Despite what your ego may tell you - there are reasons CRNAs are technicians - someone has to do the scut work after all. Accept this and stop complaining or go get the credentials required to "play doctor" for real.

  8. Oh Tess, you appear to be the epitomy of the arrogance demonstrated by some anesthesiologists. "scutwork" "technicians" are used by you as derogatory and inflammatory. Are you too foolish or arrogant to realize that this rhetoric just furthers CRNA's resolve prove that we are competent and effective practitioners? We are not doctors....we know that. But shoving your credentials in our faces proves nothing about YOUR abilities. Think before you speak...something All of us should have learned in grade school.

  9. Tess...Just out of curiosity, how long have you been in practice?

  10. Tess, Sorry, I thought that you were the one complaining, perhaps I
    misunderstood. I am very happy to hear that you and your colleagues enjoy physically practicing anesthesia and doing your own cases, I think it makes you a far better anesthesiologist and I respect that. However, I think it is sad that you think that doing cases(which is what I do), is "scut work" and a "technician's work". All of us who give anesthesia regardless of our credentials are technicians to a degree because many of the skills we perform are technical. I'm sorry but I never sought to go to medical school because I wanted a better quality of life than I thought being a doctor could provide me. I didn't want medicine to BE my life. I chose to become a nurse and always felt that nursing itself was an honorable "professional" career choice. I didn't default to nursing because I was a medical school reject, I just chose a different path. I wanted more of a challenge and so chose nurse anesthesia. I wanted to "think" and to care for patients one on one, not 40 at a time. I wanted to make an impact on people's care, to make a difference. I never felt I was practicing medicine, nor did I want to. The nursing process involves clinical observation, and hands on implementation of care based methodologies. I am not making a diagnosis by treating pain anymore than a PACU nurse is, or an ICU nurse is by treating an arrhythmia. Do medicine and nursing overlap? Yes, and they should overlap and interface. Do you have skills that I do not? Absolutely! You can practice peri-operative medicine and I cannot. I have done this a very long time, worked independently for most of it, and done it well without mishap. Am I practicing medicine?? No! I would not be able to do that nor would I want to. I am practicing nurse anesthesia in the primary care setting of the OR. I am observing the patient's depth of anesthesia and treating their pain and comfort needs( warmth, fluid, pressure points, respiratory/ventilatory care etc). and I am well trained to do that. Clinical application of anesthesia is an art as well as a science. It takes observation of the patient's condition, listening to their physical and emotional needs, and applying anesthesia priciples in a customized way. This is no more or less than what any critical nurse is expected to do. Nurse anesthesia is application of the nursing process as it applies to the patient under anesthesia. It is technical yes, it is clinical yes, and it involves nursing judgement. All well within my "skill set". I'm sorry if I offend you, it is not my intent. I am just explaining why I feel nurse anesthetists can and do perform anesthesia well (as shown by the recent studies in the opt out states).

  11. cont'd.
    The fact is that there are not enough anesthesiologists to do all the anesthetics necessary, the fact is, that many rural areas are very underserved by MDAS. Are you doing a great service by undermining their confidence in CRNA driven anesthesia delivery when it is shown to be safe and an effective model of care?? Patients in all areas of the country deserve epidurals and spinals and pain blocks as well as those in urban university based settings?? Why deny them that when CRNAS can offer patients the same services safely?? Isn't that somewhat self-serving of the MDAS?? CRNAS have safely and independently provided anesthesia services to our military for years, why are CRNAS less desirable for the rest of the poplulation?
    The fact is, MDAS and CRNAS are both here to stay and there is plenty of work for both of us. Let us do what we are trained to do. We do not need another anesthesia provider to WATCH us do what we already can do. By working together we can IMPROVE delivery of anesthesia services to every patient that needs care. There are BAD providers of all credentials everywhere, lets work together to ensure that all anesthesia providers are competent and unimpaired. Let's stop fighting each other and fight what's wrong with the health care system! Who better to improve health care than those of us who provide it!!

  12. I was not intending to post but will. I am a critical care anesthesiologist. I am always trying to get my colleagues involved in perioperative care in the ICU but the majority would rather get a root canal--even some who are prior practicing intensivists. If you complain that technological advances have enabled those with non-physician training to provide safe anesthesia to most healthier patients undergoing surgery. Well, that's what has happened. It is true with EVERY specialty. Every specialty has "low hanging fruit" procedures that are easy and pay well. However, these are being taken by less trained folks because people figure out that the specialist is not needed to do them. Non-surgeons are now doing tracheostomies at the bedside--I do them, quickly and safely. Non-surgeons do the majority of endoscopies now. primary care docs do gyn procedures and superficial biopsies (I used to do those as well). We need to just tough up and start recognizing the fact that if we want to be known as the "experts" in anesthesia, then we need to accept that most of our patients need to be the tougher ones, the sicker ones and stop complaining when the easy cases go to someone else--it is called Resource Allocation.

    So, PLEASE, if your group's critical care trained doc asks for help in establishing a service that might not pay great in the short term but gains the group job security in the long run, support her or him...and remember this blog discussion! Thank you.