Who is responsible for your anesthetic? A doctor or a nurse? On March 28, 2021 the anesthesia world in the United States was rocked by the headline: “Wisconsin Hospital Replaces All Anesthesiologists With CRNAs.“
The hospital was Watertown Regional Medical Center, located in Watertown, Wisconsin, population 23,861, midway between Milwaukee and Madison. The medical center previously had an anesthesia staff that included both MDs and CRNAs (Certified Registered Nurse Anesthetists). Why did this change happen? The article didn’t say. The article did say that “Envision, a large medical staffing agency that works with the hospital . . . will oversee the anesthesiology team. A quote from the Medscape article read: “Adam Dachman, MD, a surgeon at the hospital, speaking for himself, said he has no problem using nurse anesthetists. (He said) ‘It’s a misconception that physicians are required to administer anesthesia.’”
Is this a watershed moment for the profession of physician anesthesiologists? Are CRNAs going to replace MD anesthesiologists all over America, changing the profession forever?
In a word, no.
Will certified registered nurse anesthetists (CRNAs) will be major factor in anesthesia care in the 21st century? Yes. See this link. There are roles for both CRNAs and physician anesthesiologists in the 21st century.
Let’s step back and look at healthcare practitioners from the view of a patient. Let’s say you’re a patient, and you enter a medical clinic for a checkup. An individual who is not a doctor interviews you, it’s usually quite clear by their nametag and by their verbal introduction whether they are a physician, a nurse, a physician assistant, or a nurse practitioner. Each of these job titles has a different educational background, a different duration of training, and a differing level of autonomy and responsibility. If a physician assistant or a nurse practitioner presents themselves as your healthcare provider in a clinic, you realize you are not being attended to by a physician.
When you enter a hospital or surgery center for a surgery and an anesthesia professional approaches you prior to your surgery, that professional could be a physician anesthesiologist, a Certified Registered Nurse Anesthetist, or an Anesthesia Assistant (AA). Each of these job titles has a different educational background, a different duration of training, and a differing level of autonomy and responsibility. If a CRNA presents themselves as the sole anesthesia professional responsible for evaluating you and making the anesthesia plan and carrying out all the anesthesia care, you realize you’re not being attended to by a physician.
Are CRNAs and anesthesiologists equals? No, they are not. The difference in training is profound. CRNAs are registered nurses with a minimum of one year experience as a critical care nurse followed by, on the average, an anesthesia training period of three years. Anesthesiologists are medical doctors, and their training of four years of medical school followed by a minimum of four years of anesthesia residency following makes them specialists in all aspects of anesthesia care and perioperative medicine.
Physician anesthesiologists frequently employ CRNAs to assist them in the anesthesia care team model. In this model, an MD anesthesiologist supervises up to four CRNAs who work in up to four different operating rooms simultaneously. The responsibility for the anesthesia care in this model resides with the supervising MD anesthesiologist.
The American Society of Anesthesiologists STATEMENT ON THE ANESTHESIA CARE TEAM “Anesthesiology is the practice of medicine including, but not limited to, preoperative patient evaluation, anesthetic planning, intraoperative and postoperative care and the management of systems and personnel that support these activities. . . . This care is personally provided by or directed by the anesthesiologist.”
Governors in 19 primarily Western states (Wisconsin, Arizona, Oklahoma, Iowa, Nebraska, Idaho, Minnesota, New Hampshire, New Mexico, Kansas, North Dakota, Washington, Alaska, Oregon, Montana, South Dakota, California, Colorado, and Kentucky) have signed legislation allowing CRNAs to opt out of physician supervision and practice anesthesiology alone. The primary motivation for this change was the fact that hospitals in rural communities had inadequate numbers of physician anesthesiologists. Empowering CRNAs to work alone made surgery more accessible to patients in these rural areas. I have no personal connection to or communication with the Watertown Regional Medical Center, but a small community like the one in Watertown Wisconsin likely was unable to recruit or retain a full lineup of MD anesthesiologists, so they were forced to staff with CRNAs. The Watertown Regional Medical Center website, under “Find a Doctor,” as of April 25, 2021 listed 3 MDs and 10 CRNAs.
Is there any data that CRNA anesthesia care is less safe than MD anesthesia care? There is. Doctor J H Silber’s landmark study from the University of Pennsylvania documented that both 30-day mortality and failure-to-rescue rates were lower when anesthesia care was supervised by anesthesiologists, as opposed to anesthesia care by unsupervised nurse anesthetists. This study has been widely discussed. The CRNA community dismissed the study’s conclusions, citing that the Silber study was a retrospective study.
An anesthesia blog, Great Z’s, recently posted a column titled CRNAs Take Over America. The column said, “the anesthesia care team model will be the end of physician anesthesiologists. With the ACT model, anesthesiologists’ roles become more like physician assistants. We’re outside the operating rooms, dealing with preop history taking, starting IV’s, making sure the patients are ready for their surgeries. Meanwhile, the CRNAs are the ones that are administering the anesthesia. They are the ones the surgeons will interact with 90% of the time. Our interactions with surgeons diminish to the point where they feel the CRNAs are doing all the work and no physician anesthesiologist is needed. This makes the hospital administration’s decision to save money by firing all the anesthesiologists that much easier and less controversial with the staff.”
I disagree that MD anesthesiologists will be pushed out the doors nationwide. Easy anesthetic cases can be done by either MDs or CRNAs, but complex cases (open heart surgery, brain surgery, neonatal surgery, surgery on patients with multiple medical comorbidities) will nearly always require physician anesthesiologists. I believe surgeons will support the role of physician anesthesiologists in their operating rooms. Surgeons have no incentive to replace physician anesthesiologists with CRNAs. Patients have no incentive to replace physician anesthesiologists with CRNAs. Would CRNA anesthesia care be less expensive? There is a paucity of data to support that, with only one study to date, published in a nursing journal (Journal of Nursing Economics) which concluded that, “CRNAs acting as the sole anesthesia provider cost 25 percent less than the second lowest cost model.”
In California where I live and work, Governor Arnold Schwarzenegger signed the independent practice for CRNAs into law in 2009. California physician anesthesiologists were angry and concerned about the legislation change at the time, but in the 12+ years since 2009, the penetration of unsupervised CRNA practice in California was been minimal. The traditional old models of physician-only anesthesia or the anesthesia care team are still the dominant modes of practice in California.
One threat that remains troubling is the specter that national staffing companies (see the Watertown story above) may force out MDs and hire predominantly CRNAs, collect the standard anesthesia fees for each case, pay the CRNAs less than they paid MD anesthesiologists, and therefore increase profit to the shareholders of the parent company. What can anesthesiologists do about this problem? Don’t sell your anesthesia practice to a national company. But if your hospital CEO makes an exclusive contract with such a company, it’s possible you could be forced out without any choice.
CRNAs will have a significant role in American healthcare in the future. The most significant role will be played with an MD anesthesiologist at their right hand supervising them. Non-supervised CRNAs will be found mainly at rural hospitals. I don’t see a significant number of unsupervised CRNAs working in Palo Alto, Manhattan, or Boston anytime soon.
The future for physician anesthesiologists still looks bright.
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