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Prove It

June 10, 2016

I was recently honored by a request to write a piece for the journal Outpatient Surgery.  Having duly provided a pithy and witty ditty about the Veteran’s Administration MD vs CRNA kerfuffle, the editor dutifully came back at me with an edit.  He said:  “Can you give a specific example of how the broad knowledge of medicine gives MD anesthesiologists an advantage?” or something to that effect.  Hmmm… trying to stir the pot, I thought.  Controversial?  You want controversial?  I thought.  So I sent out an email/text/tweet to my colleagues specifically asking for examples of how the broader knowledge of medicine gave them an advantage when it came to the safe practice of anesthesia.  Here are some of the responses I got (my friends will likely cease to be my friends after I post this):

“They’re [CRNAs, I assume] often pretty cocky and it’s usually because ignorance is bliss.”

“Just doesn’t demonstrate a solid foundation in the basics of physiology or pharmacology.”

“They often can’t think outside the box.”

“Physiology, pathology, pharmacology, anatomy is just not there.  I think it’s a depth of knowledge and problem solving skills.  Everything they know is very superficial.”

“Pathophysiology.  That’s why we make the plan.  They can complete it very competently, but don’t have the extent of knowledge regarding all conditions to make the safest plan for the patient.”

Of all these responses, the last is the only one that comes even close to a specific reason for the existence of the MD anesthesiologist.

Please don’t misunderstand – I truly believe that the presence of an MD in the supervision of the administration of anesthesia is very important.  But, friends, we need to be very specific and persuasive.  Simply saying “it’s not safe” and “we know better” isn’t going to sway administrators who see cost savings instead of patient savings.  We can’t just say we’re worth our price.  We have to prove it.


From → Healthcare

  1. Alex permalink

    Did you have a change of heart? you were so supportive of NP’s taking over primary care and you questioned the qualification and greater competence of MD Primary care Docs. Now this is happening to anesthesiology and you are shocked that hospitals will always look at their bottom line and will prefer cheaper midlevel CRNA at the expense of physician based care? I know an anesthesiologist who lost his job because the group wanted cheap labor. I’d laugh if you lost your job to a CRNA because of the administrators desire for cheaper labor.

    • I have tried in this blog to present a balanced viewpoint. I’m not supportive of anyone taking over anyone else’s job, but your comment shows the real issue here, which is turf. You are worried about your job. Doctors are worried about their jobs. As I said in my last post, if, as I believe, doctors ARE a necessary part of the health care team, we as physicians need to prove our worth. That’s the world we live in now. It is not enough to say “Oh nurses don’t know as much pathophysiology.” In what specific ways is this a problem? In what ways are patients put in danger by this lack of knowledge? If you can’t give specifics and sell your product, at your price point, you can’t complain when the cheaper competition takes over.

      • I am glad to see someone actually point out the elephant in the room.

        There is a significant amount of evidence showing independent CRNA practice is equally safe and cost effective to boot.

        The fact of the matter is that all the evidence points to equivalence. The often spewed BS by the ASA is that “a true randomized trail cannot be done”. That is correct but the fact is se dont need one, we already know.

        140 years later if independent CRNA practice put patients more at risk or resulted in negative outcomes it would have LONG since ceased. It has not. CRNA malpractice rates, set by actuaries who could care less about CRNAs and MDAs, is less than 1/3 that of MDAs working independently in a similar practice. Surgeons malpractice rates do not increase working with independent CRNAs, hospitals do not have to pay a premium to use independent CRNAs. If there was ANY calculated increased risk actuaries would have long ago found it as a way to make MORE MONEY on insurance premiums. There isnt. That should be the evidence that resonates the most.

        If that was not enough maybe these quotes from MDAs will:

        Also here are the quotes:

        In fact, a highly respected anesthesiologist, R.K. Stoelting, MD wrote the following in the December 1996 issue of the journal Anesthesia and Analgesia:

        “… Unchallenged acceptance of the conclusion that evidence supports a specific method of anesthesia care delivery to be the “safest and most cost-effective” is misleading to patients, colleagues and those responsible for shaping health care delivery policy…

        …. Likewise, the participation of certified registered nurse anesthetists (CRNAs) in delivery of anesthesia care would have ceased many years ago if there was evidence that this participation resulted in a less favorable outcome compared with anesthesia personally administered by an anesthesiologist…..”

        ….Judging quality of anesthesia care on the basis of outcome(mortality) is unlikely to show a difference between personal delivery of anesthesia by an anesthesiologist and anesthesia care that includes a CRNA, with or without medical direction…”

        Again, from the December 1996 issue of Anesthesia and Analgesia, , J.P. Abenstine, MD and Mark A. Warner, MD state:

        “…The argument that superior education and experience will always offer better outcomes is inconsistent with any available data, whether in reference to anesthesia care, obstetrical care, or many other medical and nonmedical activities within society. You may need to be an electrical engineer to design a television, but you don’t need to be one to fix one….”

        The fact is MDAs have a more broad education, however it clearly has made no impact on the outcomes of anesthesia.

  2. Hi Shirie,

    This article intrigues me as a medical student. It encompasses a much larger debate centered on medical economics, but I think it is based on human character and marketability more than anesthesiology as a profession.

    If you look at the professional standards of anesthesiology (via ASA):

    “Anesthesiologists are physicians first and anesthesiologists second”


    “Professionalism must rest on a solid base of education, experience and skill and must encompass real respect for other professionals as well as patients.”

    In other words, one must achieve sufficient education, experience, and skill to meet the societal standards of accepting patient care responsibilities as a physician. Marketability aside, anesthesiology is not a service, it’s a profession that exists out of need of physicians to enable life-saving and life-lengthening procedures on behalf itself and of other professionals, and that demands both the seriousness of accepting the responsibility of patient care, and the ability to understand the details of human pathophysiology in order to communicate within the physician profession. Ultimately the goal is to relieve human pain and suffering with a high level of safety and certainty.

    Just as CRNAs are nurses first and anesthetists second, the outcome of CRNA service is irrelevant if they are unable to legally accept patient responsibility AND communicate patient details within the realm of the physician profession–both purposes which demand a solid educational base.

    This “excess” education may seem irrelevant to hospitals who have an economic responsibility of being profitable, and to legislatures who only seem to understand the word “service” but not “profession”. However, it ultimately imparts the two factors which I mentioned above which I think are key to maintaining anesthesiology as a legitimate physician practice. Hospitals, and health insurance companies, and even malpractice lawyers owe their existence to the physician profession, not the other way around. Otherwise, there is nothing stopping anesthesiologists from becoming a CRNA or “surgical anesthetic assistant” or “person who doesn’t think pathophysiology is important in medical care” or whatever you want to call yourself.


    • Three things I would say. First, the question of “service” vs. “profession” is a fascinating one, and thanks for pointing it out. Many hospital systems hire anesthesiologists to “provide anesthesia services” for their patients. This implies that anesthesia is most definitely viewed by administrators as a service, and as such can be contracted to the lowest bidder. I think it is partly this view that puts anesthesiologists on the defensive. Second, The idea that CRNAs know nothing about pathophysiology is hogwash. They have advanced nursing degrees. They think pathophysiology is just as important as anyone else. Lastly, You are right, the physician profession is at least partly responsible for the healthcare systems we have now. Doctors historically have tried to put their heads down and do things the way they’ve always done them, hoping market forces and regulatory bodies would leave them alone. Now we’re scrambling to regain some of the contro we lost while we weren’t paying attention.

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