The Independence debate in Anesthesia

The independence debate in anesthesia. #anesthesiologist #physician @nmsahq @asahq Physician-led anesthesia care team provides patient safety, which is the #1 priority in patient care. #va #patientsafety #healthcare

The physician vs. crna debate has reared its ugly head…. yet again.  There have been multiple bills presented to suggest crna independence WITHOUT physician anesthesiologist oversight.  In 2017, proposals were made to the Veteran’s Affairs to replace physicians with crnas.  Here’s what they found when they looked at the VA databases to conclude that nurses will continue with physician oversight in anesthesia:

Current laws in 45 states and the District of Columbia all require physician involvement for anesthesia care and the VA in 2017 decided to maintain its physician-led, team-based model of care. The VA’s Quality Enhancement Research Initiative (QUERI) could not discern “whether more complex surgeries can be safely managed by CRNAs, particularly in small or isolated VA hospitals where preoperative and postoperative health system factors may be less than optimal.”

Here’s my evidence and reasons why I believe the care of the patient is best when it is physician-led.  After all, would you want a nurse or assistant doing your actual surgery?  The ultimate goal is patient safety.

Physician anesthesiologists have up to 14 years of post-graduate medical education and residency training, which includes 12,000-16,000 hours of clinical training, nearly seven times more training than nurse anesthetists.

From 2010:

From 2011:

From 2017:

 

Yet, here’s another debate that shows there’s no difference in an anesthesia care team setting with an anesthesia assistant and a crna:

Bottom line in my opinion:

  • Physicians endure years of grueling medical education that starts with the why, how, and treatment of disease. This is followed with years of residency training in anesthesia. There’s also further training in the form of a fellowship for specialized fields.
  • Getting into medical school is an extremely competitive process. You take the top 1% of college graduates and high MCAT scores to get into medical school.  The board certification for becoming certified in anesthesiology is quite complex and difficult in both the written and oral board exams.
  • I will continue to be FOR team-based physician-led anesthesia care.
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The physician anesthesiologist vs. CRNA debate

Why is this even a debate?

It seems to me that the CRNA-led debate is financial… once you tease through all the fluff.

So here’s some literature I found:

As an anesthesiologist, I work in an MD-only anesthesia group. This is by choice: I prefer doing my own cases and being responsible for my own liabilities. The times I have required an anesthetic, I have requested a physician anesthesiologist. As a resident, I had very good insurance coverage, so I wanted a physician for my surgery. At that time, I was ok with having a resident anesthesiologist paired with an attending anesthesiologist for my case. My second surgery was done at my current hospital, and we only have MD anesthesiologists. Perhaps I’m biased? I know and I understand the path/journey/training it takes to get to become a physician anesthesiologist. I want someone who is well-trained, independently thinks, vigilant, and knowledgeable.

I’m sure there are great CRNAs out there… but when I was a resident… we used to supervise CRNAs in our final training year…. and it was scary some of things they would do. Who extubates from a trach R&R on 30% FiO2? Yeah, that particular CRNA told me they had 30 years experience. 30 years experience of doing something wrong doesn’t equate to 30 years of knowledgeable experience. And let’s not forget that CRNAs need a 15 minute morning break, 30 minute lunch break, and 15 minute afternoon break and they go home when their “shift” ends (even if it’s in the middle of a complex case). I take a break when I can… I eat lunch and take a bathroom break when I can…. and I choose to stay and finish complex cases for better continuity of care.

Would you want a nurse practitioner or physician assistant solely performing your surgery without a surgeon? I know I would NOT. I think there’s plenty of room for teamwork in healthcare. This is how to improve hospital efficiency and patient care. My fear is if CRNAs gain independence for purely financial reasons. But then, they will have to carry their own liability, cover their own breaks, take night call and discover that they had it so good in a healthcare team.

Opinions from other physician anesthesiologists:

 

Bottom line in my opinion:

  • Physicians endure years of grueling medical education that starts with the why, how, and treatment of disease. This is followed with years of residency training specifically in anesthesia. There’s also further training in the form of a fellowship for specialized fields.
  • Getting into medical school is an extremely competitive process. You take the top 1% of college graduates and high MCAT scores to get into medical school.  The board certification for becoming certified in anesthesiology is quite complex and difficult in both the written and oral board exams.
  • I will continue to be FOR team-based physician-led anesthesia care.

How MD anesthesiologists have become victims of their own excellence

The Doctor, by Sir Luke Fildes (1891)
Image via Wikipedia

Taken from  KevinMD.com’s blog:

How MD anesthesiologists have become victims of their own excellence

Comments below that tended to resonate with my thoughts.

Med Nerd At Large January 22, 2011 at 6:20 pm

It seems like the author is criticizing medical students and physicians for choosing certain specialties as opposed to primary care. While we do need more primary care providers, simply supplanting roles traditionally held by physicians will only compromise patient care.

To examine the author’s primary example, the CRNA vs MD debate, yes most CRNAs can provide equitable anesthesia to most patients as their MD counterparts. I can attest to this fact as I see it on a daily basis as both a medical student and an anesthesia tech. However, while the author may claim that it doesn’t matter who’s behind the curtain during your average cholecystectomy, any anesthesiologist knows that it makes a world of difference the second that patient unexpectedly goes into laryngospasm.

The moment something goes wrong, the first thing a CRNA does is call for the anesthesiologist. This may be an uncommon scenario, but completely replacing Anesthesiologists with CRNAs might make the difference in those patient’s survival. Patient care is ultimately compromised by the simple fact that they’re not getting “the best.”

This truth can be extrapolated to the rest of medicine. Yes, a tech/PA/nurse with less medical training might get the job done 80% of the time, but what about that remaining 20%? Are you as a parent comfortable taking your child to a PA who will most likely misdiagnose your child’s sudden fever and malaise as a viral syndrome, when in reality it’s Kawasaki’s resulting from a previous virus and could potentially kill them?

CRNAs are great, as are PAs, nurses, and techs. I know, love, and work with a lot of really great ones! But they should stay CRNAs, PAs, nurses etc. and not try and play doctor. They’re might be very capable in their respective professions, but they aren’t trained to be physicians and many should quit kidding themselves.

And I’ll choose whatever specialty strikes my fancy without feeling an ounce of guilt. As for primary care, I’m not busting my tail through nearly a decade of medical training, sacrificing my twenties, and taking on nearly $200,000 in debt to work a job that only pays 3/4 that yearly and forces me to keep working 80+ hours after residency. I want to have a family and a life outside of medicine too. So yeah, I’ll keep killing myself now and enjoy that ENT job later. I’ll make more money, work less hours (still 60+), have less headaches, and see my wife and children more. And I’ll be better at my job than any tech with less training. Who would you rather have doing your thyroid surgery?

James Gaulte January 22, 2011 at 7:14 pm

The Lewin Group is a subsidiary of Ingenix which is owned by UnitedHealth Group. Clearly a health insurer is interested in a less expensive way to delivery care..This study plays into that nicely but will we hear a rebuttal from the anesthesiologists ?

The anesthesiologist vs. CRNA debate ends here.

This website defines the essence of physician care in the field of anesthesiology. Want to know what separates an anesthesiologist from an anesthetist? Check out the link. Plus, it lists tips on what to ask and what to bring for your upcoming surgery.

http://www.doctorbyyourside.org/Get-The-Facts.aspx

My own thoughts on this debate