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The MD-CRNA wars continue, despite voices of reason

January 7, 2015

A front page entry in the December 2014 issue of Anesthesiology News: Physicians Versus CRNAs: Redefining Roles in the Changing Landscape of Health Care.  Sounds like a prize fight or a gang war; Crips Versus Bloods.  I immediately got my own boxing gloves on, readying myself for another bout of vitriol and dislike thinly disguised as concerns for patient safety.  But the author, Michael DeCicca, a second-year anesthesia resident, surprised me.

“Logically the number of ambulatory, diagnostic and less-invasive cases for the newly insured will increase at a greater rate over time than the complex, open, marathon cases reserved for the very ill.  These simpler cases fall well within the ability of CRNAs.  When looking at indisputable facts, unsupervised CRNAs operate at a lower up-front cost to the health care system. Making value judgements about CRNAs as a group is as effective as a Luddite throwing rocks at a loom.”

OK, you say, but DeCicca is just a resident, he doesn’t know anything, and after all he has no skin in the game yet.  He’ll change his tune.  Plus, I can’t remember what a Luddite is, the cheeky showoff.  Perhaps.  But the young are often the first to sense and welcome change.  Residents are in a position to closely observe the business into which they will be jumping and to sense the way the wind blows.  Luddites, by the way, were artisans of hand-made lace and textiles who tried to defend against the inevitability of the mechanical loom by trying to destroy it.  DeCicca poses the question at the core of all the fighting:  “How do we anesthesiologists remain competitive in a market where a cheaper alternative is available?”

Anesthesiologists response to this question has been mostly defensive: restrictive legislation, outcome studies, political lobbying.  We have responded to our perceived threat in the same way the pharmaceutical industry has responded to the presence of cheaper alternatives in the form of generics, older and less expensive proven drugs, and Canadian products.  Lobbying to prevent foreign imports or internet sales, aggressive marketing of the newest drugs, and patent litigation far overshadow willingness to participate in a competitive international market.  In fact, in the very same issue of Anesthesiology News there is the report that the ASA is spending $470,000 to internally research the association between MDs and CRNAs and clinical and economic outcomes.  Responding to a challenge by Dr. John Neeld in 2013, the study is the latest in a load of research trying to prove one group is better than the other.  The Cohrane Database, which deals in meta analysis of groups of related studies, has already weighed in with the conclusion that “no definitive statement could be made about the possible superiority of one type of anesthesia care over another.”  Dissatisfying for both sides, I’m sure.

DeCicca answers his own question in the same way that I have on this site and others, in a much nicer way:  “We must highlight the value of our unique expertise.”  Physicians are more qualified to take care of the big cases, the sick patients, the complex anesthetics.  We should embrace those challenges.  Average, everyday plodding through healthy ambulatory cases is not going to be enough anymore.  We have to be The Guy, the manager of care, the one everyone looks to for answers, the one patients consider with awe and respect.  Not just “Anesthesia” at the head of the table.  Now I have someone next to me when the rotten tomatoes come out.

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6 Comments
  1. Mark lazar permalink

    I agree mostly. But the caveat is that ambulatory patients are no longer healthy. Having worked at level 1 trauma for 15 years and ambulatory for 6 years in a business model system, I can assure you that on average, I am taking care ASA3 to 3.9 pts 50-60% of the time. I rarely see ASA1 patients. Less than 2-3%. So the reality of current and future outpatient care is indeed a battleground and the future of anesthesia financially. So call me a Luddite but I know where the money is and it’s not in hospitals

    • The thinking is that more people insured means more healthy people getting “screening” tests that require sedation, and thus more people healthy with positive results getting surgery. Agree that ambulatory surgery is not just ASA 1s and 2s anymore.

  2. Agree. But here is where the issue is, in that if you are getting riskier cases, your pay should be dramatically higher than routine cases. If it is easy, it should be done for $50 an hour and if it hard, the fee should be $200 an hour. This has always been my issue with mid-levels, wanting to do the routine stuff at the same cost as the hard stuff.

    • I think the payment system is supposed to do that – so many points per unit of time based on ASA status. I might be wrong about this.

  3. Jayden permalink

    This is all fine and good until your 32 year old healthy c section patient has an amniotic fluid embolus and requires massive rescuscitation. I would not want my wife in the hands of a nurse in that situation….and I have seen plenty of these in my career. One of many complications that could happen at any time to any patient….

    • That’s why I don’t advocate independent nursing practice. I totally agree that when things go wrong, when a patient is really sick or really complicated, a doctor should be there. No question.

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