We have met the enemy, and he is us....

I'm back...

A year or so ago, I was walking down the OR corridor between cases, and a surgeon I had known for fifteen years pointed at me and said sharply; "come on; what are you doing wandering around? - take the patient back!" I was momentarily confused, since we weren't working together that day. It was good that I was disoriented for that brief moment, because it gave me pause before the anger rose in me; a pause long enough that I suppressed whatever growl would have otherwise erupted. I was four steps away by the time I figured out that he had forgotten who his anesthesiologist was for that day, and he thought I was it... (and I use "it" intentionally). When I passed by a couple of minutes later, he simply said "I thought you were my anesthesiologist." Maybe a little sheepish, but then again, maybe not. And I thought, "he treated me like he treats the nurses..." Here's an amusing account of a sociological study on why surgeons behave like surgeons...

My co-author, Andy's post "Should Physicians be the Leaders of Anesthesiology" received  lots of hits in the days after it was posted, mostly directed from CRNA discussion sites. That little pissing contest reminds me that nothing much has changed in the anesthesia world; everybody is still fiddling while Rome burns. Twenty years ago I intentionally left the anesthesia care team world for an MD-only practice. It's not because I didn't like nurse anesthetists or supervising/collaborating with them; I did. What I didn't like was the way surgeons treated me in the care team role. They treated me like a nurse; it sucked. Nobody should be treated the way surgeons treat nurses; is it any wonder there is a nurse shortage? And the average age of nurses is now hovering at 50, which is a good thing, because no surgeon, no matter how testosterone driven, is inclined to fondle/pinch/squeeze/leer-at a 60 year old nurse with a wrist splint and gray thinning hair. When I left my academic post, I had had a stomach full of bullying from surgeons; I had seen anesthesiologists physically assaulted (pushed and shoved, yanked and lifted off the ground by the collar), amidst an endless stream of verbal and psychological abuse. Belittling, browbeating, and a general air that anesthesia was something you did if you weren't smart or motivated enough to be...a surgeon.

In residency at Wisconsin, we fought back pretty effectively, but at Mass General and thereafter, surgeon behavior was shocking. There's an old saying at Wisconsin; anesthesiologists are either doormats or land mines. I was a land mine. If this was academics, I would have none of it. So, I left. When I came to Las Vegas, my personal situation was vastly improved; since anesthesiologists were physicians, we were colleagues, not subordinates. Nurses were still treated poorly, but I was excluded from the pounding for a long time. Times have changed here, but that's another story for another day...

As I rose in leadership to chief of staff and medical society president, I was very intolerant of physician abuse of nurses. In this I was aided by the Federal civil rights laws barring sexual harassment; all of a sudden, the hospital became liable if surgeons were allowed to back nurses against a wall and fondle them, or if charts were thrown at them. (yes, these things happened.) Mind you, this was not common, but twenty years ago, it was tolerated by hospital administrators with an attitude that was part "boys will be boys" and part calculated tolerance of inappropriate "client" behavior (surgeons bring paying customers-that is, patients.) Nothing like the threat of federal fines and civil lawsuits to fuel an epiphany and put starch in administrative shorts. As for the physicians involved, they, amazingly, seemed to think it was a "right" (droit de signeur?) or something. Perhaps they had come to expect it, or their mama's just didn't raise them right. I don't know.

Becoming chief of staff was not without its surgeon challenges. When I appointed an ophthalmologist as Chief of Surgery, a self-important cardiac surgeon mounted a rebellion designed to make himself chief of surgery, in order that he might "supervise" my leadership, since I was subordinate in his view. This insurrection was, ahem... crushed. As chief of staff I received written death threats against myself and my family, almost certainly based upon my insistence upon adherence to bylaws, civility, and maintaining concern for patients. Fortunately, we all survived. There's more, but discretion, and my lack of desire to have my post vetted by my attorney ($300/hour) preclude some of the juicier details of my leadership experiences; after all, it is Las Vegas. Maybe in another decade...

So, what about the CRNA's and independent practice? Personally, I think to any outsider, it looks like a commercial dispute. The CRNA's want the money, so do the MDAs. Here, as I see it, are the facts.

1.) either I'm stupid, or I know something the CRNA's don't. That's four of college (MIT, chemical engineer) four of Med school, three of residency and a critical care fellowship, vs. four of nursing school and two of anesthesia. It took me that long to feel reasonably competent, and I was (and am) still learning and improving; so maybe I'm dumb, and those nurses that took half the time are just twice as smart...

2.) I'm not sure that a simple hernia or routine cholecystectomy needs my level of preparation. I'm sure that a valve replacement or cerebral aneurysm clipping does.

3.) The best CRNAs are better than the worst MDAs. A diligent, compassionate CRNA is better than a disinterested, inattentive MDA. Period. Beyond this, there is considerable overlap. But nothing beats a good anesthesiologist.

4.) In a number of situations, anesthesia care team MDA's take advantage of their supervisory position to loaf. In many other settings, the MDA's use the flexibility of their positions to add incredible value to the hospital setting. Acute pain, leadership, critical care, teaching. The military has a nice model.

5.) On a level playing field, if a patient/payer can have an MDA for the same price as a CRNA, they will choose the MDA. That's what happened in Las Vegas. CRNAs get the same reimbursement as MDAs, so guess what? And MDA partners (and associates hoping to be partners) will put up with much more crap (lots of call, no breaks, no lunch, canceled vacation) than CRNAs.

6.) When the VIP (Senator, Congressman, or tycoon) needs anesthesia, an MDA is involved, either care team or MD only; even for a hernia. Feel free to contradict me if you know otherwise...

7.) CRNA training programs have done nothing-I repeat, nothing, to advance the art and science of anesthesia. They are merely dishing it up as designed, researched, and prescribed by academic anesthesiologist/scientists. It would be very short-sighted of the CRNA leadership to undermine academic anesthesia, (as they have apparently been doing) since it will inevitably, eventually deprive them of the differential respect that they seek to capitalize on when they demand three or four times the income of their critical care nursing companions. If they want to bang away at private practice MDA's, so be it; private practice MDA's contribute nothing to anesthesia's intellectual future or credibility, either. If the price of supporting academic anesthesia is a few more MDA's to compete with, the AANA should be glad to pay the price.

8.) We don't need AA's. Lowering the bar to undermine CRNA's as a political ploy is a bad idea. Doing so in order to stretch resources (increase efficiency/make more money) is a bad idea too; it undermines the ASA arguments regarding levels of skill required; nobody is fooled by the CRNA's claim of intellectual equivalence, and nobody is fooled by the claim of supervision making up for lesser skill of AA's either... It's the money. That's all that drives the system then; not quality.

9.) My academic co-authors describe a blight in academic anesthesia that threatens all our futures; CRNA, MDA alike. If the CRNA's want to fight for independent practice, go for it. I'm sure the ASA will give them a run for the money... But everbody ought to pitch in to save academic anesthesiology and the anesthesiologist/scientists that it has traditionally bred, because otherwise CRNA's will get kicked around like the nurses they still are. And they won't like that. And private practice MDA's,  If you don't believe that you need to pitch in, go up to your ICU and see how many patients are paralyzed/ventilated and sedated to unconsciousness, all being managed on protocol by an RN. And then, have a long, hard think about what makes you different...

I leave you with a reference to  the first article of the first issue of anesthesiology, published in 1940. The title is "The Place of the Anesthetist in American Medicine."  Nothing seems to have changed in 70 years...

Comments

[Terri Anderson CRNA]

I would like to remind you, that most CRNAs have years of experience as ICU, ER, or flight nurses. Before we became CRNAs, we were the nurses you hoped would be caring for your patients. We worked hard to learn more than our colleagues, and we took initiative to advance our skills and ablilities. Now that we are certified anesthetists, you hold us in contempt. Terri Anderson CRNA

[Gibbitt]

That was erudite, refreshing, and made me smile. Thank you. After supervising CRNAs for a few years, I am 10 years in an MD only practice, and it's great. I don't miss the biliousness which is dripping from the above post onto mine, or the daily struggle of some CRNAs to be validated constantly. I can just do my job and not worry about someone else doing theirs properly. And I would say to Terri, that the above post did not seem contemptuous to me, and yet, was summarily labeled as such by you, and that illustrates the whole issue in some ways of the reductionistic thought which inherently leads to conflict. i.e. It's just not that simple.