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Taking Sides

June 12, 2015

Let me first say that I am not, nor have I ever been, in favor of independent practice for CRNAs.  I know a lot of my detractors think I am.  Thus I come to the MD vs CRNA argument with the general understanding that physician anesthesiologists should, in general, oversee the work of their “midlevels”.  The problem is that I suspect that even if the independent practice issue, which is mostly coming from the CRNA governing societies, not individual CRNAs, were off the table, the battle would still rage.  And now I think I know why. In the world of anesthesia politics something odd is going on.  While opposition to CRNAs among physicians is vocal and strident in the upper echelons of the high mucky-mucks in the American Society of Anesthesiologists (ASA), state societies of anesthesia are being encouraged to welcome another group of “midlevels”: Anesthesia Assistants.

What is an AA, exactly?

Here is what the AAAA (American Academy of Anesthesiologist Assistants, of course) says in their career flyer:

Anesthesiologist Assistants are highly educated allied health professionals who work under the direction of licensed anesthesiologists to develop and implement anesthesia care plans.  AAs work exclusively within the Anesthesia Care Team environment as described by the ASA.  AAs are trained extensively in the delivery and maintenance of quality anesthesia care as well as advanced patient monitoring techniques.

Ah.  So, they’re like CRNAs.  What’s the difference?  AA programs are based on a masters degree model.  So are CRNA programs.  AA programs require two full academic years and accepts students who have prior education in the sciences.  So do CRNA programs.  Let’s see, what else… physiology, pharmacology, anatomy, biochemistry, patient monitoring, life support, patient assessment… Yup.  All the same.  However, there is a significant difference: AA programs typically require a bachelor’s degree with all the premed requirements, and the MCAT (or GRE, for the faint of heart).  CRNA programs require a background in critical care nursing and a bachelor’s degree in nursing or related field.

Anesthesia Assistants are trained under the prevailing medical model, while CRNAs are trained from the nursing side.  AAs, therefore, are under the umbrella of medical certification, and indeed the certifying exam for AAs is administered and scored by the National Board of Medical Examiners.  CRNAs are certified by their own organization, and as such are separate from the dictates of medical societies.

AAs and CRNAs do the same work.  Yet no one is yelling about AAs taking over physician anesthesiologist jobs.  You see, AA societies are much more controllable by state medical societies, and AAAA would never, ever, suggest independent practice. AAs are firmly on the doctors’ side, since sides are being taken.  According to the most recent issue of the ASA newsletter, the Ohio Society of Anesthesiologists voted in September of 2012 to include AAs as members.  Here’s what Dr. Basem Abdelmalak, OSA president, said:

“When we met with the Ohio AAs, we found that we share the same passion for excellent care.”

(OK, but CRNAs have the same passion for excellent care.)  He continues:

“We have the same understanding and expectations of the anesthesia care team model and the roles of different members of the team under the direction of the physician anesthesiologist.”

Bingo.  Those Anesthesia Assistants are speaking Dr. Abdelmalak’s language.  CRNAs are not.  That’s the problem.  That’s why the fight continues.  That’s why sides are being taken and barricades built.

I call on the ASA and the AANA (American Association of Nurse Anesthetists) to sit down with each other and create a common language. Medicine and Nursing should not be on opposite sides of anything.  We should all be working together.





From → Healthcare

  1. Hi Sheri: I am suspecting this is a parallel situation to the NP/PA “thing”. Not so much that we do not get along actually I think we are more aligned than not. What I do see is strong preferences for one discipline over another by MDs. PAs being educated in the medical model, NPs in the nursing model, both master’s level, NPs now having to enter with a DNP degree. Deb

    • Robert Ford Crna permalink

      At UC Davis in Sacramento NPs and PAs train side by side taking the same courses. At the end of the training NP students are qualified to take the PA exam but not the other way around. PA candidates cannot take the NP exam since they lack that all important credential of an RN license that physician types like to look down their noses at. That’s OK. Just look where public policy and opinion are going. Nurses are a very trusted and capable group. Physicians of course love AAs especially because they are 100% under the thumb of the MD.

      • You’re right. It’s policy. At the individual clinical level I think we all are working together.

    • Very much so. My point is that there doesn’t need to be this gulf.

  2. “It is difficult to get a person to understand something, when their salary depends on them not understanding it.”

    – Upton Sinclair.

    I work independently as a CRNA. No i dont just do bread and butter PS 1-2 cases. No there is no MDA. Yes “midlevel” is the most insulting statement ever created by the AMA (yes it was them). Because clearly an RN is a “low level” a CRNA/NP is a “mid level” but you really want the ‘high level’.

    So lets not be confused or confuse the readership. I do the SAME job as an MDA. Not less than, not different than and the outcomes are the SAME without anyone ‘supervising’ me.

    If MDAs and the ASA want to compete then so be it! Im ready! Stop trying (the ASA) to control, restrict or otherwise demean/limit my profession legislatively and lets just COMPETE in the market place! LEts do it. All states will opt out, CRNAs in every state will be able to work independently (PS they do now), and we will compete for contracts. Stop hiding behind the patient safety BS and be honest it is really about $$$ and protecting your piece of the pie.

    AAs are nothing more than a distraction who cannot work to full scope of practice, do not expand services, do not help rural areas, do not decrease costs and were created for one reason, to protect MDAs from having competition. However, they are ALREADY talking about being able to work independently. How quickly you guys have forgotten about the AA who sued in Ohio to expand their practice or the bill in NM to allow them to work without an MDA present. That is just the start!

    Lets stop pretending and be honest. The ASA cares about money, not patients. The ASA has made it their mission to push a 3rd competitor for MDA and CRNA jobs, the ASA attempts to limit legislatively the practice of CRNAs. The AANA does NONE of these things. We spend ALL our time defending the BS that the ASA continues to spew.

    CRNAs do practice independently in every state of the nation. Opt out has NOTHING to do with that. States who have not opted out means the HOSPITAL has to have “supervision” to meet the conditions of participation for medicare part A. That is what hospitals bill not what WE bill. That condition, BTW, has nothing to do with MDAs and simply requires either the surgeon to “order anesthesia by CRNA” or to have the bylaws say the same is assumed for every case. No liability incurred no control and no concern. Opt out simply removes this COP for medicare part A. Its a perception thing not a real one.

    Lets get over the BS. If you want the AANA and the ASA to work together then tell your association to stop telling the AANA they have to accept the ASA’s BS “Anesthesia Care Team” statement in order to do so. Yah, thats what they expect. What a joke and it will never happen. So much could be accomplished if they could be honest and stop pretending superiority where there is none.

    That would be a start.

  3. Alan Bokar permalink

    For a medical school “graduate,” your grammar is embarrassing.

  4. Anoynomous permalink

    My Aunt is actually an AA and she begged me to go the CRNA route over AA, because of how hard it was for her to start AA school with such limited clinical knowledge- and she feels like it took her years to get to the same level as the CRNA’s that started with her. She is a competent care provider, but so am I- and I think our mich better prepared as a new graduate CRNA than any AA would (I feel fairly confident in that- no offense to AA’s because I know there are very intelligent ones, but clinical experience goes along way.) Also, I would do a little research on what the requirements for both CRNA school and AA school really are…I (gasp) did have to take the GRE before I started CRNA school…and the classes I took in undergraduate for nursing were actually much more focused on actual medical practice than what most “premed” majors are (let’s be honest there is not a premed major..premed means you can major in whatever you want as long as you to take two chemistries, two biologies, A&P, calculus, Micro- some places require physics too.. I actually took all of those same classes before I went to (gasp again) nursing school and I have to say having those classes don’t even begin to prepare you the way clinical experience does…I am all for higher education in terms of classroom experience [I wouldn’t be working on my doctorate if I wasnt] but I think doctors and AA’s would be much better prepared if they had clinical experience starting as early as CRNAs do – in undergrad.) check your sources and try again!

    • Anoynomous permalink

      Also I did this from my phone and cannot figure out how to edit it- I’m sorry for the terrible choppy sentences/grammar mistakes… I went back through and made some adjustments and didn’t take words out/changes tenses apparently .I obviously can’t work my iPhone.

    • I have often thought that all training, in any field, would benefit from a year of real-life experience beforehand.

      As to entry requirements, I’m sure your bachelor’s preparation was just as rigorous as any premed. The point here is not to compete for who has the most education, or really to compete on anything. We’re all doing the same work, so we should work together.

  5. cantbullshitme permalink

    I just called Joan Rivers, she said , dam it where was my CRNA when I needed them!

  6. Nick permalink

    Here’s the ASA playbook for those who want to know:

    Objective 1: Create a 3rd provider to compete with and undermine CRNA jobs. Check

    Objective 2: Make this 3rd provider legally tethered to you as a doctor so that they will always have to co-exist with you. (i.e. Legally prohibited from independent practice, and therefore a non threat to your job as a doctor). Check

    Objective 3: Lobby legislation in ways which promote this 3rd provider as a interchangeable option to CRNAs. (i.e. Licensing in each state to increase market penetration). Check

    Objective 4: Implement ACT models in as many practices across the country as possible. Make these ACT as restrictive on CRNA practice as possible, thereby limiting CRNA skills in regional techniques, central lines, etc. This will give the Anesthesiologist a market advantage over a CRNA who cannot provide the same services.

    Objective 5: Exploit the results of objective 4 with hospital administration and legislators, which will create a positive feedback loop. The suits will see CRNAs as a less qualified inferior choice. Hospitals and legislators will implement policies against independent CRNA practice. Check

    Objective 6: AAs will begin to work alongside CRNAs and slowly replace CRNAs in those ACT jobs. Check

    Objective 7: have a stranglehold on the market and control salaries so that the doctors can stuff as much money in their pockets as possible while the real workers are just happy to make 1/4th to 1/3rd of their actual gross revenues generated.

    AAs = job security and big salary for Anesthesiologist. Nothing less, nothing more.

    • Cindi permalink

      Nick’s statement was spot on. It has everything to do with control of crnas and limiting our practice (ego and money). The ASAs egocentric policy on APNs, specifically CRNAs is unfounded and not backed by any evidence….other than some incorrect statements that I am a physician so I know more because I may or may not have ‘more schooling’. From these notions you determine that you must be safer. This isn’t true and its not proven!

      Next “when seconds count…”. This is the most ridiculous Medical society statement out there. I would be pissed if my medical group created this propaganda; and to boot an Anesthesiologist Day seeing that no other physician group has their own day. It only makes your group look insecure, esp within other medical specialties. There are no other medical groups out there working so hard to promote themselves and ‘crush’ competion.

      Having been in health care since 1989, I would be most happy to have a CRNA take care of me. Just because your an MD doesn’t make you safe, efficient, patient centered or skilled. Those ASA doctrines are unfounded and unproven.

      • Thanks to all for the comments. Just remember that both sides are taking sides. CRNA rhetoric has been just as negative as doctors’. Attacks on the ASA from the nursing side don’t help any more than salvos coming from the other direction.

  7. Rural CRNA permalink

    I am a CRNA in a rural practice. When providing anesthesia I am “supervised” by the attending surgeon per State law. For the most part this supervision amounts to “anesthesia per CRNA” and little more. I am responsible for the pre-para-post operative care of my patients. The harsh reality that the ASA and militant MDA’s refuse to admit to themselves or the public at large is that the vast majority of anesthesiologists don’t want to work where I work. They don’t want to actually provide anesthesia nor do they want to “direct” in a small rural setting. There is not enough money in it for them. That is the reality.

    If the ASA had their way patients in rural areas away from large metro medical centers, MDA controlled care teams, AA’s, and medically directed CRNA’s would not have anesthesia and therefore not surgery at all. Or, as suggested by some of the very anesthesiologists that don’t want a long commute to their work, these patients can drive hours to a large, cold metro medical center for their surgery.

    Yes, I provide anesthesia without an anesthesiologist present. I do it every day, nights, weekends, and holidays. I do this not simply to enrich myself but to provide a service to the community in which I live, work, and raise children.

    The ASA lives in a fantasy land where safe, competent anesthesia can only be provided by a anesthesiologist. This idea has no basis in fact or foundation in reality.

    Show me an anesthesiologists who wants to work where I do, the hours I do, and serve the patients I do. I’ll send them an application… We can split the call.

    Good day,

    Rural CRNA

  8. Anonymous permalink

    Funny that Dr. Basem Abdelmalak works at The Cleveland Clinic- Main Campus and only works with CRNA’s, SRNA’s and residents. There are no AA’s at Main campus.

  9. An M.D. not an MDA permalink

    In the early 1900’s ether was the most common inhaled anesthetic in the USA. It was relatively safe and easy to use so the job of administering it generally fell to one of the lower ranking members of the operating team, frequently a medical student, recent graduate or nurse. As with most skills, they get better with practice so some surgeons began to train specific nurses to administer the anesthetic and nurse anesthesia was born (under physician supervision).

    In the UK, chloroform was the most commonly used inhaled anesthetic. It had a much narrower therapeutic window and only physicians were allowed to administer anesthesia so there are no nurse anesthetists there.

    Since then there has been an amazing amount of improvement in anesthesia safety and efficacy mostly driven by physician anesthesiologists. However, there are not enough anesthesiologists to serve every area that needs them and CRNA’s fill that gap.

    Administering anesthesia is the practice of medicine so it legally must done by a physician or under the supervision of one. Optimally the supervision would be by an anesthesiologist. While CRNA’s are well educated and have extensive training, its still far less than what one receives as an anesthesiologist.

    I don’t like the approaches of either the AANA or the ASA to the current problems but fortunately most of us anesthesiologists and CRNAs get along just fine. When things go awry as they sometimes do, the CRNA’s I work with are glad to have my help.

    • Very true. In the earliest years of anesthesia med students and house officers didn’t really want the job and weren’t very good at it. The best success in maintaining a reliable anesthesia practice was when nurses took it over. However, never was it the case that nurses worked “unsupervised”, although back then the supervising MD was the surgeon, who, just like today, doesn’t know anything about anesthesia!

  10. While I disagree with some of your points, overall, I have to say that it’s been awhile since I’ve a read that take a moderate conciliatory tone versus the typical vitriol I often see and read in blogs regarding the CRNA/MD dynamic.

    I work at a major academic university with a variety of anesthesia providers (CRNAs, SRNAs, residents, dental anesthesia residents, and of course, attending anesthesiologists) providing care a for a number of patients (ASA I-V) in a variety of different settings (off-sites like cath lab, IR, MRI, and main OR). In this setting, I work in a medical direction model. However, as this is probably not much of a surprise to anyone who works in this setting, I often develop my own anesthesia plan for my patient and my attending is only around when an emergency arises or if I have questions regarding the patient’s care. That said, that’s not to say that because I often work alone, I am making the argument I should work independently. In fact, I am very appreciative of the fact that I work at an academic institution where I am surrounded by individuals who are committed to the mission of expanding the knowledge and practice of anesthesia. I am fortunate to have access to such resources and as a result, I feel as though I am able to provide a high level of care.

    At the same time, I work at a number of surgery centers providing care as an independent provider. I perform regional and neuraxial blocks in addition to providing MACs and GAs and I provide it through a strict adherence to the standards of how we’ve all been trained (whether CRNA, AA, MD, or DDS). It’s through this experience that I have learned and will continue to learn how to be a stronger, independent provider.

    That said, I often struggle with reconciling the chasm that exists for me working in anesthesia care team model and a setting where I’m working alone. Perhaps the struggle is specious as the environment at both settings are different from one another. Taking care of patients in a surgery center is not the same thing as taking care of patients in an academic medical center, which is true, but at the same time, I work at 6 different sites at this center, 3 of which are outpatient surgery centers and in the academic setting, I work under the medical direction model. Again, this is something that I’ve yet to fully learn to reconcile.

    In any case, I’ve always been a proponent of our professional organizations taking less of an adversarial and antagonistic tone with each and more of a conciliatory relationship. I’d like to ask how both sides can find that common ground with each other. It’s something that I think would be highly beneficial for both sides. Too often, I’ve heard anecdotes from both sides about each other’s intentions, most of which center around protecting one’s financial interests, which I find to be baseless, unsubstantiated and ultimately, cynical.

    However, as I’m writing this, I also wonder how or if the AANA and ASA can ever play nice with one another because this really comes down to how each organization views the role that the CRNA plays in the perioperative experience. Until we can clearly define that role and how that role fits in the spectrum of perioperative care, I fear that we’ll never be able to find a common ground with which to build a relationship. Perhaps there’s another angle to this discussion that I am overlooking. Thoughts?

    • I forgot to mention that I’m a CRNA, but I gather you’ve probably come to that conclusion after reading this post.

    • This really comes down to money. All arguments, a wise man once said, are ultimately about money.

    • Mike MacKinnon permalink

      Hi ucla

      So you are aware the reason why the AANA and Asa do not meet in the middle is because the ASA refuses to do so unless the AANA states they agree the anesthesia care team lead by MDAs is the best model. It isn’t and so we are never going to admit it is. Now you know why there is so much angst. You can thank the Asa.

      I would let you know there are level 1 trauma centers where crnas own the contract and provide all the services for it. Also there are major centers where crnas perform the hearts independently and do their own tee.

      Initials do not equal ‘better’.

  11. Lobal Jones permalink

    I am a SRNA and we are informally mandated to attend some of the state association meetings and events. Feel like we are being coached to feel uneasy of MDAs. Agenda is how MDAs/ASA work against at the state and federal level to control CRNA scope of practices. Eventually, it is about the money and I could loose my salary. I wonder whether they do this in other health science programs.
    Hopefully, this is not a national trend in NA. How can this create a good teamwork ? What do we do when boomers run out ? If it is like this in a healthcare boom time.. things can get really ugly in 30-40 years from now. I remain hopeful to be a team-member in a friendly team, I really don’t mind having a MDA as a team leader.

    • B. Pitcher permalink

      Unfortunately TEFRA (Tax Equity And Fiscal Responsibility Act Of 1982) passed allowing MDA’s to bill for the work of CRNAs. There are 7 requirements they have to meet in order to bill for our work. It is not easy to meet all seven requirements. This encourages less scrupulous MDAs to bill without actually meeting all seven requirements. Other health care professionals cannot bill for the work of others in this same manner,

  12. B. Pitcher permalink

    After reading your “opinion” piece it is obvious all your education did not prepare you for a reasoned and intelligent argument based on research, To deny the abundant research done on this topic and to only express your “opinion: flies in the face of modern medical practice: I hope you use actual research findings to treat patients and not your opinion. If the consequences weren’t so serious I would actual find your opinion amusing. Please for the sake of your patients restrain yourself to actual research when choosing a course of actions.

    Praying for your patients.

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