Introductory note on language: In the US, an anesthesiologist is a physician, an M.D. with 4 or more years specialty training in the field after completion of medical school; with rare exceptions, all are board certified by rigorous examination by the American Board of Anesthesiology. An anesthetist is a nurse, a C.R.N.A. (certified registered nurse anesthetist). New graduates have a BSN (bachelor of science nursing and a MSN (master of science nursing); a total of six years of schooling plus one year working in ICU, for a total of 7 years. A significant number still practicing have neither degree, but are ‘grandfathered’ under the less rigorous former standard. Not so in the United Kingdom, where ‘anaesthetist’ generically describes whoever is administering ‘anaesthesia.’ Until recently, as far as I know, anesthesia was administered only by physicians in the UK, but the “anesthesia care team” (more below, and likely the best) model has been introduced and is growing in prevalence in order to extend physician manpower.
Undergoing anesthesia today is nearly 100 times safer than it was 50 years ago. Why is that? Because anesthesiologists – physician scientists – developed devices and procedures designed to improve safety. As an anesthesiologist, I frequently say to patients, “I understand that you did not come here today to see me. The best evidence that I have performed at the highest level will be your forgetting all about me when you leave the hospital.” The combination of improved safety and the veracity of this statement makes for a perverse consequence: in the mind of the general public, anesthesiologists lack any constituency; nobody says – compared to surgeons, say – “that is my anesthesiologist.” Our services are self-limited, impersonal, interchangeable. We only seem to exist when things don’t go perfectly, when we are called into account. We are one of the few professions still held rigorously accountable. These facts of life have important practical and political consequences in America, as will become clear below.
Only about 20% of anesthetics are administered by physicians alone, one-on-one with a patient. The vast majority are provided in the “anesthesia care team” mode, where one physician medically directs the activities of up to four nurse anesthetists CRNA’s simultaneously. Medical direction means the physician evaluates each patient pre-op in order to determine if the patient is fit to undergo anesthesia in the first place, and if so, prescribes the anesthesia plan (general or regional, as well as many other decisions as to techniques of ventilation, medications, gas mixtures, monitors, vascular access, etc., etc.). Suffice it to say that the combinations and permutations are complex, varied and consequential. These decisions, taken before the anesthetic per se has begun, are highly determinative of outcome.
After prescribing the anesthetic and explaining it to the patient, the physician then obtains proof of informed consent in the form of a signature on a witnessed legal document. The physician then personally performs or directs the CRNA in performance of a nerve block, spinal, or epidural, or directs and assists at induction of general anesthesia. In long cases, we visit intermittently, while performing all these same duties with other patients under our care simultaneously. In the event established parameters of vital signs are exceeded or if the surgery deviates from usual, the CRNA calls the physician to intervene. We are called to be present for emergence, render all necessary care in recovery room and discharge patients from there when ready. We take care of all complications and answer for them, even if caused by others. CRNA’s have no experience answering for complications.
Now, the great radical egalitarian tsunami of American culture (see Bork, Slouching Towards Gomorrah) has not finished crashing on shore and crushing all structures before it. It is, however, a bizarre and incoherent egalitarianism. While one must be licensed by the state in order to clip another’s cuticles, today CRNA’s are on the brink of being allowed to administer anesthesia independently, “in competition” with and as “equals” of anesthesiologists. Pending legislation requires that all licensed institutions like hospitals and surgery centers not discriminate in any way between them. This is the American ideal now carried to its absurd, illogical extreme: discrimination is not only prohibited due to race, creed, sex, etc., etc., but also is forbidden on the basis of training, competence or demonstrated and time-tested ability! All this, in a country where “safety” can reliably trump any other value in furthering state intrusion into the lives of everyone. Incoherent.
Since all that matters in modern America are perceptions, do you imagine for a moment that any state or federal legislature would dare to elevate nurses to equality with surgeons? Can you imagine arriving at the hospital only to learn at the last moment that a nurse will perform your surgery, not a physician? This is what I mean by having a “constituency.” Now, this in no way is intended to denigrate the skills of nurses generally or CRNA’s in particular; they perform excellent and valuable services. It is merely to assert unequivocally that there are significant differences in skill sets as well as depth of knowledge, training and ability between the two groups. l aver, also unequivocally, that differences in ability between the two groups result in part from the far more rigorous selection process in admission to medical school (at least that has been the case until identity group and “victim” status came to trump merit in most all endeavors) compared to nursing school.
While there are surely overlaps in ability as to outliers in the two groups, when it comes to native intelligence and innate ability, this difference is undoubtedly expressed as a probability function: however unfashionable it is to say so, physicians are most likely to be superior to nurses as measured by intelligence, innate ability or any other objective performance criterion. This is as would be expected, given that the activities engaged in by physicians are far more complex with significantly higher stakes as to outcome. The public, by and large, understands this and this understanding explains why regulators will never substitute nurses for surgeons or reduce the training requirements of commercial airline pilots (unless it is done in the dead of night for correct progressive reasons and thus with media connivance via silence).
While I in no way attempt to diminish the role played by CRNA’s individually, their professional organizations defame anesthesiologists as a matter of course. This group is bold in self- promotion and belittling anesthesiologists, notwithstanding these facts:
- CRNA’s have never had to answer for bad outcomes. That responsibility until now has fallen to the physician anesthesiologist or the surgeon, even if it was caused by the negligence of the nurse anesthetist (respondeat superior).
- Their relentless argument to legislators that they are the equivalent of physician anesthesiologists requires one to believe that I have wasted 7 years of my life (I have 7 more years education and training than they do;many of my colleagues have 8 more years via subspecialty fellowship). Either that is true or we have risk management backwards (the three pillars of improved quality in any risky endeavor are training, training and training). The only logical alternative is that nurse anesthetists are so superior as a group, a priori, that they can learn everything that I did in seven fewer years!
- Regularly, this group of nurses, whose members immediately demand (there have been lawsuits won by them and Medicare/Medicaid already pays them the same) the same pay as physician anesthesiologists, defame me and my colleagues by saying that physicians are only resisting their independent practice to protect our own income. One would think such blatant unprofessional, actually slanderous conduct would give legislators and regulators pause as to motives of the nurses…but no – this is modern America, where envy is a (if not the) major force behind all politics.
- Let’s say I am working in an OR where CRNA’s are my “competitors.” What happens when one of their patients gets in trouble. Who do you suppose the surgeons and OR staff are going to seek out to rescue the patient, to fix the problem? Another CRNA?? If 60 years of work in OR’s is any guide (40 of them as an anesthesiologist), I can say with some assurance they will be looking for me to assume responsibility (and liability) for a patient in extremis whose problem I might well have prevented in the first place by virtue of my superior training.
- Perhaps most telling of all – in a culture where “choice” has been elevated to sacramental status when it comes to certain issues, the poor aforementioned patient in extremis, above, will never have been offered the choice of who administers his/her (for simplicity’s sake, in an attempt to include all possible patients, I refer only to birth sex, since considerations of gender have nil effect under anesthesia) anesthetic. Others – hospital administrators most likely, will decide who provides anesthesia in a given institution. The patient’s “choice” will be to sign or not the pro-forma “informed” consent form handed them as a matter of routine immediately before the procedure (virtually no one ever reads these documents). The patient will definitively NOT be offered a choice between an anesthesiologist and a CRNA. This despite scores of appellate decisions in state and federal jurisdictions, which wax eloquent, poetically extolling the virtues, indeed the absolute necessity of fully-informed consent prior to medical procedures. Do you think a reasonable person just might think this includes knowledge of the qualifications of the individuals who will literally be holding his/her life in their hands.
All of which leads to my only possible response to this lunacy. I will never work for one minute in an OR where CRNA’s are my ”competitors;” I am perfectly happy working with them in the teammode, asI have done for 40 years. To “compete” would place me in both an intolerable ethical dilemma and at unreasonable legal jeopardy. Were I to work under these conditions, it would be generally expected that – after the hospital, CRNA, and patient (unknowingly) have excluded me from the patient’s care a priori – were I present in the OR, I would be expected to ”help out” with emergencies which will inevitably arise for the CRNA’s patients. No thanks. What am I supposed to do, for instance, if I am giving a patient anesthesia, by myself (i.e. not medically-directing a CRNA) who did ask for my services? Leave my patient? Sorry, I can’t abandon a patient who did ask for my services. Alternatively, if I am on a break or between cases, it is fundamentally unfair to expect me to take on this responsibility and this liability – a fortiori if I could have prevented it in the first place. Yet, as anyone who has ever worked in an OR knows, that is precisely what everyone will expect of me. If those are the rules of engagement, don’t expect to see me on that battlefield. I will never work in that irrational and astoundingly unfair system.
Which leaves only the question: qui bono? Little or no money will be saved overall; it will be redistributed. The same amount of money is paid per anesthetic regardless of who administers it or how. In the care team mode, that amount is split between the physician and the nurse. By directing multiple cases and doubling or tripling his/her liability exposure and workload (and becoming involved often-tendentious OR management, scheduling etc. to boot), a physician may make a small increment in income compared to simply doing his/her own cases, hands-on, one at a time. My own preference would be to do that; it is a much less stressful undertaking compared to directing 2 or 3 CRNA’s simultaneously. So, little or no cost saving will result, notwithstanding the nurses’ hortatory remonstrations. Hospital administrators may be seduced at the outset by such arguments, until actual experience administers a dose of reality in the form of notably increased liability costs.
Thus, the CRNAs’ income will increase. Physicians involvement in anesthesia will be either diluted to down to (theoretically) “supervising” care (i.e., not be involved in all cases; merely put out fires and sign on the line that says M.D. = malpractice defendant) or excluded entirely from patient care. Those hospitals which employ any anesthesiologists will likely have one and one only. That sorry individual will administer only ink to paper or pixels to flat screens in the form of “policies and procedures” so when the hordes regulators blow through sporadically, the hospital will look good structurally (kind of like how the Constitution’s structural safeguards of individual have (not) worked). As this is directly analogous, think teachers’ registers in public schools. There, numbers and checkmarks are found in every row and column, neatly written as required. Totals appear at the bottom of each column; well-regulated, orderly, even color-coded. Looks great on paper. The only problem is that the majority of students can’t read, write, do arithmetic or think critically. As with progressive public schools, so with future anesthesia (If Republicans were in charge of city schools, the “media” would make this state of affairs a national scandal, non-stop).
As you read, regulators and legislators – poseurs, really when it comes to safety – are undoing the far safer existing system of anesthesia which has been hard won over the past few generations through physician leadership and research. To the detriment of patients, this is being undone in secret, with none of the zealous “investigative reporting” reserved nowadays for deployment only against Republicans or conservatives and their policies – and truth, in that regard, is optional in reporting. This fight, as I understand it, is about progressive compulsive deconstruction of systems in which merit and/or authority rightly reign. The only part I can’t understand is the role played by those who purport to be lobbying for anesthesiologist associations. All they want is money to offer legislators. I have asked them why they don’t go around the legislators and appeal directly to the public. It is not a hard case to make to the public. I haven’t received an answer to my question. And unlike over many years in the past, they haven’t received my money. They most recently reported they can’t get any legislators to side with us. So, it seems, the battle is lost.
In my numerous letters to legislators over the years (the nurses have been waging this war for 20 years or so), I suggest they have the courage of their convictions. If they believe safety will not diminish, I ask, why not create a mandatory registry of anesthesia complications and record whether or not a physician directed the anesthetic? I have never received even an acknowledgement of my letter, much less an answer to my question. Airline crashes, you see, are newsworthy since many deaths occur simultaneously. Anesthesia mortality, by comparison, is sporadic. The way our “media” works, that is not newsworthy, precisely because those deaths are sporadic – occurring one at a time – even though the total number likely exceeds those from average annual airliner crashes by a factor of two or more. This, of course, is another progressive tactic I will entitle “fake non-news.” If the “media” don’t report it, it didn’t happen. If they did report the facts responsibly, legislators would never dream of gutting the medical specialty of anesthesiology.
Next time you have anesthesia for surgery, inform yourself as to who is taking care of you. Nobody else will. You are on your own. The ever “safety-minded” state is not really in the business of protecting you when you are at your most vulnerable; it is counting on your not ever knowing the risk to which you are being exposed. And, as with those who never receive the benefit of a drug which never came to market because of regulatory roadblocks, there is no constituency among those who die in preventable anesthesia mishaps. Other than sporadic, highly-local and unpublicized negligence lawsuits, these are silent victims when it comes to determining government policy.