The doctors, the nurses, and the anesthesia

American Society of Anesthesiologists
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This was taken from The New York Times:

The Doctors, the Nurses and the Anesthesia

Published: September 11, 2010
To the Editor:

Who Should Provide Anesthesia Care?” (editorial, Sept. 7) proposes allowing nurses to deliver anesthesia without the supervision of any doctor. Both of the studies cited to support this approach have been financed by the American Association of Nurse Anesthetists.

When did The New York Times start taking policy positions based on purchased research? If the editorial page is going to take a position, your readers deserve some degree of critical and impartial analysis.

The irony is that the remarkable safety of anesthesia underlying the assumption that anyone can do it is purely a result of physicians’ innovation. Without physicians, patients are unpredictably put in danger, and further advances are impossible.

Alexander HannenbergPresident, AmericanSociety of AnesthesiologistsNewton, Mass., Sept. 8, 2010

To the Editor:

Evidence supporting the safe and high-quality treatment by certified registered nurse anesthetists cited in the editorial is only one part of an important puzzle.

At the same time that the Research Triangle Institute and the Lewin Group have reported that nurse anesthetists practicing in California and 14 other states where physician supervision is not required are as safe as nurse anesthetists practicing in states requiring supervision, we learn from a RAND study on work force that anesthesiologists will be in short supply and we will have an “oversupply” of nurse anesthetists. Truly a divine coincidence!

Given the demonstrated safety of nurse anesthetists, let’s allow them to practice as they have been prepared and focus on rightsizing the needed ratio of anesthesiologists and nurse anesthetists. The scientific evidence suggests that every successful surgery does not require an anesthesiologist.

Catherine L. GillissPresidentAmerican Academy of NursingWashington, Sept. 9, 2010

To the Editor:

Your editorial missed the opportunity to point out that a nurse anesthetist or an anesthesiologist doesn’t have to be an either/or choice for the patient. My patients had the best of both worlds — anesthesiologists and nurse anesthetists working as an anesthesia care team.

Anesthesiologists have continued year after year to develop newer and safer techniques that reduce the risk of anesthesia complications for even the sickest patients. Nurse anesthetists are able to use these newer and safer techniques, and if both professionals are working as a team, every patient will have access to the skills of the nurse and the medical judgment of the physician anesthesiologist when the most serious problems arise.

Harry H. BirdHanover, N.H., Sept. 7, 2010

The writer is professor emeritus of anesthesiology at Dartmouth Medical School and was president of the American Society of Anesthesiologists in 1988.

To the Editor:

No one doubts that the co-pilot of a jetliner can, under most circumstances, fly the plane effectively. But I doubt that many people would feel comfortable flying in a 747 across the Atlantic without the captain in the cockpit. Why should anesthesia care be any different?

Nurse anesthetists are skilled professionals who, with supervision and backup, can provide excellent care. But every anesthetic needs a captain. And that captain needs to be a physician anesthesiologist.

Andrew GorlinBoston, Sept. 7, 2010

The writer is an anesthesiologist.


The feud/debate continues regarding anesthesia providers.  One simply can’t look at a study that was financially backed by nurses as the end all debate — don’t you see the misrepresentation of information?  I’m wondering if this study included ASA 3 or greater patients, emergency calls for MD anesthesiologists, types of surgeries performed, major academic centers vs. ambulatory surgery vs. private practice, etc.  I think a team approach to medicine is very valid, however, let’s not lose site of the fact that physicians who undergo rigorous training and residency experience are very well-equipped to handle medical emergencies and therefore have a dedicated leadership role guiding the care of patients through anesthesia.

I feel that media and government place such high emphasis on cost-effective medicine.  But, is it really cost-effective if there are more complications, longer hospital stays, etc?  I would have to see how the study was conducted, methodology, analysis of results to truly believe that there was no statistical difference between MDs and CRNAs.  Here’s a question: Would you pay the rate of seeing a dentist if you were only seen by the dental hygenist?

Don’t get me started on what I think about insurance companies and middle man groups who continue to corrupt health care efficiency and cost-effectiveness.   Doctors end up wasting more time filling out forms and getting denied access to appropriate therapy/treatments for patients… who are these insurance entities to dictate what is best for patients?  Yes, definitely akin to a dictatorship.

There’s an oversupply of CRNAs because the route to become one is certainly shorter and possibly less competitive than applying for medical school and competing for residency spots for anesthesiology.  Would CRNAs be held liable for the work they perform solo?  I can only imagine that their malpractice insurance will go up.  Now, they want to add doctorate of nurse anesthesia…  is this a joke? If they want to be called doctor, why not go to medical school… incur the debt… lose years of normal socialization…  ???

Here’s an excerpt taken from Doctor of Nurse Anesthesia:

Do doctoral degrees for nurses generate confusion about who is a “doctor”? Historically, the title “doctor” refers to both academic (PhD) and professional (MD, DDS, DPM) degrees and acknowledges a higher degree of educational attainment in an area. Traditionally, only medical doctors practicing in the hospital setting were called “doctor.” It has been suggested that patients may become confused if other healthcare workers are addressed as “doctor,” and trust in the doctor-patient relationship will be eroded. No evidence exists that patients are confused about who is an MD (medical doctor) or DO (doctor of osteopathy) and who is not. Nurses are proud to be nurses and routinely identify the nature of their profession and practice, regardless of the particular degree they possess. There is no credible evidence that nurses who currently hold doctorates use their credential and title in a way that misleads patients. In addition, ethical concerns require that CRNAs identify themselves appropriately as “Certified Registered Nurse Anesthetists” in the clinical setting, no matter what their level of education.

This whole topic gives me ulcers.  Shame on my specialty for allowing ourselves to be so open and teach/help healthcare providers to deliver safe anesthesia.  I wonder what would happen if anesthesiologists got fed up with the whole issue… formed a union… and declared a strike.  It’s hard to do surgery on an awake patient.   I wonder if the American Society of Anesthesiologists has conducted a true anonymous poll asking anesthesiologists to rate their experience with CRNAs or vote on solo-CRNA practice.  Anyone have this info?

Author: Kris

Grew up in a small Texas town. Heavily involved in extracurricular activities: piano, violin, dance (ballet/jazz/tap), tennis, horseback riding (english/western), taekwondo, basketball, soccer, volleyball, percussion, drumline, orchestra, band, mascot, pageants. I had the typical Tiger Mom upbringing. Went to college, medical school, residency, and fellowship. Amidst the ups and downs of life, allow me to share with you my an "ordinary" person who happens to be an MD.

2 thoughts on “The doctors, the nurses, and the anesthesia”

  1. A comment from someone on another blog:
    Tess said…
    As a practicing CV Anesthesiologist who is double boarded – the growing autonomy and arrogance of CRNAs is absurd – not to mention downright clinically scary. I have never concerned myself with nurses replacing me – Why? Because they can’t….

    Anesthesia is both an art and a science. And while CRNAs can be trained as technicians – it is the art of anesthesia in which they simply do not have the background knowledge to apply – The old adage – if you’re thinking sux – you better be giving it – comes to mind…

    Having previously supervised CRNAs who fail to recognize when the SHTF – I now do all my own cases – and there is no shortage of work – nor have I taken a pay cut.

    CRNAs as pain management specialists? Seriously? Perhaps if they stuck with Tylenol administration I’d be comfortable….

    This is an old argument. If CRNAs want to be anesthesiologists – go to med school, residency, fellowship and do the work. There are no shortcuts.

    Tess said…
    @ CLF, CRNA – No idea where you work or with whom – but you’re experiences expressed certainly don’t mirror my practices or those of the colleagues I work with… Frankly there are bad apples in every occupation/profession. If you had been able to get through med school/residency/fellowship – you would have. Despite what your ego may tell you – there are reasons CRNAs are technicians – someone has to do the scut work after all. Accept this and stop complaining or go get the credentials required to “play doctor” for real.


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