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.

[T.]

Mitch, just a friendly opinion here: I wouldn't say that private practice anesthesiologists contribute NOTHING to anesthesia's credibility. When an MDA in a community hospital provides stellar care which is experienced as such by the patient, patient's family, patient's surgeons, and attending physicians in other specialties who, for example, might be in the position of attending a code that only the MDA seems comfortable handling, there is a certain level of respect and credibility earned, albeit sometimes grudgingly expressed, if at all, by the aforementioned. Sometimes a well-trained, competent anesthesia attending is the only "face" of anesthesia out in small hospitals or in the boondocks, and conscientious private practice MDA's should take responsibility for and pride in contributing to the profession's future as a dynamic presence in the evolving health care of a given region.

[jm]

I had an absolutely horrible experience with a CRNA who believes that he knows what's best regardless of his patients' prior experiences. If I had KNOWN that he was merely a glorified nurse I would never have let him touch me. I am hard to anesthetize and I know what's best. That one singular experience has tainted the rest of the CRNA pool, sorry folks, give me the MD

[Chris]

Good Article. A refreshing if not completely objective view, it comes as close as it gets when anesthesia professionals begin critiquing their differently credentialed peers in this line of work. What gets me is the amount of irrational thinking and reasoning that comes from supposedly intelligent individuals on both sides of the fence. It makes me sad to think that so many people who do not reason through their politically motivated emotions critically and objectively can find their way into this echelon of the medical field. Only data and common sense should prevail here. Skill and value should be assessed accurately and paid for in kind. CRNAs and MDAs have valuable roles which overlap, however, MDAs are needed for more difficult cases. The nature of economics dictates the existence of CRNAs,who are trained faster and cheaper and cost less than MDAs, and who do a fine job for what their trained to do. No amount bitching will ever change that. Its amazing that some immature medical professionals dont have a firm grasp in how basic economic affects their profession. If the skill and demand is truly high for any task, than the pay will not change. Protectionism helps no one, especially society at large. No medical professional should have to put up with the equivelant of working with the emotional equivelant of a petulant child. Not all, but many adults in every line of work are just that, children who never grew up. Stop complaining and get to work. Nough said.

[Felix Chesterfield]

It's certainly a somewhat recession proof field right now. Sites like http://www.unitedanesthesia.com/ show evidence that every state is still looking for qualified CRNAs (and willing to pay for them too). Hardly something that every industry can claim right now.

[Joe F.]

I am 44 years old, single Custodial Dad of 3 kids ages 11-15, and am about to begin the Nurse Anesthesia program at Pitt. For the last several years, I have diligently worked my way through nursing school (ADN) while running a small trucking business and raising my kids in the absence of a viable mother. I continued to attend a bsn program one night a week while working as a ccu rn. After reading some of the posts here, I have to wonder if I am making the right decision. At my age and station in life, medical school training is not a feasible option. My hope is to develop a career as a CRNA and enjoy the benefits of that career, and to be able to provide a better quality of life for myself and my children. I was under the impression that the CRNA is a valuable part of the anesthesia team, and a valuable part of the Anesthesiologists practice, hence the high salaries. I hope this is the case for the majority of practicing MDA's. I get a bit demoralized when I see crna's referred to as "just nurses". While we do not receive the breadth or the depth of medical training that an MD does, and I do have the utmost respect for the training that a Physician undergoes, it's not as if we are attending a high-school vocational program. We do obtain Masters degrees at my last check, and there are educational and experience requirements to gain entry into the programs. Obtaining CRNA certification is at minimum a 7 year process. I, personally, do not have an issue being subordinate to the anesthesiologist in practice- he/she has received more training than myself and is trained to look at the patient with a more global perspective. I would expect, in return, the physician would recognize my training and level of proficiency and use his/her knowledge base to insure that I am functioning in a safe, effective manner. I do not expect to receive constant "validation" or "pats on the back"- that does not concern me. I do expect to be addressed in a professional manner, and generally do not have issues on that front. I enter this profession with the hope that this raging debate will eventually come to a resolution with the understanding that the MDA and CRNA each have distinct roles and abilities and can function within these roles effectively as a team without the in-fighting in order to provide the best possible outcome for the patient.

"and they lived happily ever-after"

Joe

[dontquit]

I'm always amazed at these posts. What starts as a great article, turns out to be an I'm better than you post. For most of the article, I think Mitch hit the nail on the head. I however think he misses the boat both on my fellow CRNA's and by the private practice MDA's.
I was on a track to be an MD, but was derailed by my ex wife. I then went into nursing as I loved to take care of people. I have certified in every specialty I was involved in, worked 7 years in the ER, and went on to CRNA school, graduating top of my class and scoring perfect on the national certifying exam. Every place I have worked has asked me never to leave, and every MDA I've worked with have stated that they see me as an equal (although I do not have the training they do) from a provider prospective.
I do see the differences in both MDA's and CRNA's. I have seen both good and bad in both specialties. I agree with the author about academia and the need to continue to push toward advances. I will not however support the attitude that we CRNA's are just glorified nurses. This notion is absurd. Remember sir, who was the first to administer anesthesia.
We do need both specialties. One without the other would be an injustice to the medical community. I agree with Chris' post for the most part.
As for Joe, continue on toward your goal to be a CRNA. Not all MDA's carry the same views as the authors and are a pleasure to work with. The profession of anesthesia is very rewarding and I recommend to every medical professional I meet to pursue this education.

[sam]

This is a great article. I always want an anesthesiologist to do my anesthesia; CRNA's just don't have the skill set if something goes wrong. Every CRNA that I have ever met was underskilled, arrogant amd totally absorbed by his/her salary (or percieved lack thereof). I recently had GA and a CRNA let the sevo vaporizer run dry (guess how that felt for 10 minutes, LMA, paralyzed and in horific pain; as she chatted merrily about her upcoming vacation)..No anesthesiologist would have been that stupid. I'm a physician; if it could happen to me, it can happen to you. CRNA's are a joke.

[Mitch Keamy]

As an MDA, I appreciate the vote of confidence; I must comment, however, tat after 30 years of practicing anesthesia, I believe that it is 9 parts compassionate diligence, and 1 part high level didactic knowledge, and that I have known many very capable nurse anesthetists. i have always said that I would rather have a diligent CRNA than an inattentive MDA, and it is true. Of course, the post was mostly about academic anesthesia; I am in private practice, but I hold my academic colleagues in the highest esteem, as should we all.
Thanks for visiting.

[John]

Great article, one question if I may. I'm NOT a physician (I'm an airline pilot), so what I know about medicine could be written on a postage stamp and I'm hoping to get an opinion on something that has been bothering me...I need GA for cancer surgery and want an anesthesiologist not a CRNA to do the anesthesia. I was told that this was fine, but when I went for surgery last week I was introduced to "Sue from anesthesia" who was to do my case and I assumed that she was an anesthesiologist. Just before surgery, I asked her how long she had been an anesthesiologist and she dodged the question, finally admitting she was a nurse only after we were in the O.R. Case cancelled. She then told me that; "she as good as an MDA, but if I didn;t believe that, she's "supervised by a MDA"....when I asked to see this mystery MDA, I was told that he was not available (great supervision)......These statements contradict each other. Is such subtle deceit commonplace? The MDA finally called me at home; his opinion on the CRNA varied from "they are highly trained nurses, not doctors" to "I would want my own anesthesia provider to be a MDA"...how in the heck is a patient supposed to get a qualified anesthesiologist to do his/her case (or do you have to be an insider?)..Sorry if this seems like a rant; I never thought that a medical service provider would deliberately mislead me as to her qualifications.Thanks

[Mitch Keamy]

Data on anesthesia care team suggests that outcomes are statistically similar to MD anesthesia and slightly better than unsupervised CRNA anesthesia, but this data is hotly contested by the economically interested sides. I believe in anesthesia care team as a model, but I believe in colleagial care in general; there is a reason there are two pilots on a commercial flight, and its not just in case one of them croaks. Having said this, not-so-subtle deceit about the circumstances of your care in the face of a specific request is unconscionable, and speaks to the integrity of that team. (or lack thereof) If it happened like you say, write the medical board, the hospital CEO, discuss it with your surgeon, and take your care elsewhere; thats what Id do. How you do anything is how you do everything, as they say...

[john]

Thanks Dr Kearny- I appreciate your useful comments. One final question: my surgeon can do my case at a hospital that at least has a MDA supervising the CRNA's; they have told me that one MDA usually supervises multiple CRNA's simultaneously. What happens if 2 cases need the MDA's attention at the same time? The analogy of two pilots is a good one; we often "supervise" other less experienced pilots, but it's always 1:1 with full dual controls on both sides. Having one MDA supervising multiple CRNA's seems dangerous. So far, my inquiries have just served to irritate the anesthesia staff at our local hospital; I will be going to a different hospital if I schedule the surgery. The chief of anesthesia told me that he would be comfortable with a CRNA doing his own GA, but then he added that he works with them every day and he would be able to pick the best one (something that I can't do). When I asked him which CRNA I should specify for my case, he told me that a patient has no choice, you just get whomever is available. When pressed on this issue, he backtracked and told me that they were all basically o.k. Thanks for your comments; I'm not getting much help on this end.

[ATR124]

great website: now the public should be wary of getting stuck with having CRNA'sdoing their anesthesia

[D]

John, why do you prefer an anesthesiologist over a CRNA? Can I choose who I want to fly me in commercial flights? May I see your flight physical and discuss the flight path alternatives avialable?
Let me expand on the postage stamp. CRNAs provide comparative safety data with AAs and MDAs. We all cook from the same cookbook and use the same ingredients. CRNAs administer over 60% of the 30 plus million surgical cases every year. The anesthesia training of a CRNA is similar to an MDA. The 4 years of nursing school really means nothing as well as the 8 years of college and medical college are meaningless to the new doctor!!! Those are just weak foundations to build upon. Trust me, if you talk shop with a new nurse or doctor you will soon discover their lack of basic knowledge. Its the residency and training period after school that determines the level of knowledge. The doctors have 1 year of basic residency covering several areas such as 1 month of surgery, 1 month of family practice, 1 month of critcal care etc., etc. During that time there isn't much decision making on their part. The nursing equivalent is the ICU (or similar type) training. The CRNA is required to have at least 1 yr but most have had several years of training/experience. That sort of training is never ending. A doctor or nurse can study intensive care for several years before grasping a competent level of care. then comes the anesthesia portion. Doctors have 3 years of residency specific to anesthesia with some lecture and classroom didactics. The doctors eventually get large complex cases towards the latter part of their training (helping out on big cases is not the same as doing your own big case). The nursing training is 28-30 months for most programs. The nurse will repeat the sequence many more times than the doctors. We will fly more planes. That is the repetitive nature of checking the engine and landing gear, checklist and going thru the sequence of induction (taking off), auto pilot, and then emergence (landing) several times. The truth is that you will receive excellent care no matter the credentials. We are experts in airway management and autonomic nervous system control. I hope this helps with the "public knowing about getting stuck with CRNAs"- your're in great hands of care.