ASA President Defends Anesthesiologists, Feebly

The American Society of Anesthesiologists is losing a public relations war with the nurse anesthetists.  There was that recent AANA sponsored study splashed across the pages of WSJ.com that claimed the care received by MDAs and CRNAs are equivalent.  Then there is this study in the Journal of Nursing Economics that claims the care provided by CRNAs is 25% cheaper than anesthesiologists without affecting the quality. Oy vey! Alexander Hannenberg, MD, president of the ASA, has been a pretty busy guy lately, putting out all these PR fires smoldering around the Society.  He was quickly trotted out to dispute the findings of this latest paper.  But upon reading his defense of anesthesiologists, it is obvious he has little substance to work with.  It reads more like a he said/she said argument.  His line of reasoning wouldn't pass muster in a high school debate class.

In this interview he makes seven points about MDAs vs. CRNAs.  I won't reprint his arguments in their entirety here but you can read his interview in Becker's ASC Review.  I'll just go down the line and give my two cents about why his assertions are weak and almost indefensible.

1. Scope of services provided by MDAs and CRNAs are not equivalent.  Maybe not completely equivalent but in reality they are quite close.  Critical Care Medicine is one field where CRNAs don't practice.  But few anesthesiologists practice CCM either.  Out of around 40,000 anesthesiologists in this country, the American Society of Critical Care Anesthesiologists only counts 563 members.  And that includes resident and medical student memberships.  So for all intents and purposes, MDA and CRNA practice parameters are practically equivalent.  What about Pain Medicine?  Here the ASA is running around the country trying to legislate pain procedures out of CRNAs' hands.  If not for legal obstacles many CRNAs would be in procedure rooms right now doing blocks just like MDAs.

2. Comparison of outcomes invalid. It is true that studies show MDAs take care of sicker patients than CRNAs.  That was also found in the WSJ article.  But the reason for that is most rural hospitals only have CRNAs staffing the ORs.  These small hospitals typically handle more routine cases.  Any complicated cases are transferred to urban tertiary care facilities.  It will be impossible to fully equalize the case complexities between doctors and nurses. Good luck trying to attract anesthesiologists to 75 bed hospitals in the middle of Podunk City, Middle of Nowhere, U.S.A. 

3. CRNAs rarely go "solo" when administering anesthesia. This argument is not going to last much longer.  More and more states are deciding to opt out of Medicare's requirement to have physician supervision over nurse anesthetists.  Regardless, taking care of a surgical patient is a team approach, or at least that's the way it was always taught to me in anesthesiology residency.  Even anesthesiologists don't always decide on the anesthesia "solo". We consult with surgeons when there is a complicated or unusual presentation.in the patient. Together as a team we decide on the anesthesia that will provide the best outcome for the patient. No prima donnas in front of or behind the surgical drapes.

4. Use of CRNAs as solo providers could cost more for Medicare patients. Here Dr. Hannenberg's argument is particularly specious.  He claims that CRNAs would actually cost more because they will order more medical consults than MDAs to "assess co-existing medical conditions." Really Dr. Hannenberg? I've ordered plenty of consultations myself if I felt the patient needed it to get through an operation safely.  Besides, many surgeons prefer to work with CRNAs precisely because they are less likely to delay a case for further medical workup, for better or worse.

5. CRNA and physician compensation are not an apple-to-apple comparison. This is actually a sad indictment against anesthesiologists but alas also true.  A hospital will have to pay nurse anesthetists overtime to work nights and weekends regardless of the number of cases performed, potentially raising their costs.  We smart anesthesiologists are so smug in our superiority that we don't mind sitting around in an uncomfortable doctor's lounge, away from our families, uncompensated, wondering when our next meal ticket will arrive in the emergency room.  There goes another sleepless night on call in the hospital only billing for an appendectomy and a couple of epidurals.

6. Study is unsubstantiated, inaccurate and questionable. Dr. Hannenberg cites a CDC study in 1980 that said comparisons between CRNAs and MDAs are unachievable since the rates of mortality and morbidity from anesthesia are so low.  And they are lower now thirty years later.  Well, it can be argued that if the difference in M&M is so low between the two professions, the nurses must be doing something right.

7. Patients prefer physician anesthesiologists. This maybe true, if the costs were the same.  But how many patients have been surprised by a bill from an anesthesiologist who was not in their insurance network and subsequently disputed or refused the charges? Do you think these people would feel more satisfaction with their hospital and surgeon if they got no anesthesia bill at all because the CRNA administering the anesthesia was an employee of the hospital and thus wouldn't charge the patient separately? Where is the study that shows patients prefer paying extra for an anesthesiologist or anesthesiologist-supervised CRNA vs. a free solo or surgeon-supervised CRNA?  (Free meaning their insurance company pays for it.) Are we afraid to find that people would not want to pay more money to be anesthetized by an MDA or MDA-supervised CRNA? And how much more would patients be willing to pay to have an anesthesiologist instead of a CRNA give the anesthetic?  $1000? $100? $10? Of course it's easy for people to tell researchers they want anesthesiologists present or nearby when the anesthetic is given.  But when they have to reach deep into their own pockets for the privilege I'm willing to bet their stories will change pretty quickly. That type of study involving real money will need to be conducted to prove we are indeed preferred over CRNAs.

As a practicing anesthesiologist, and a proud member of the ASA who contributes to ASAPAC every year, it pains me to have to write these words.  And it really isn't Dr. Hannenberg's fault that his arguments are so anemic.  We anesthesiologists are so busy in our ivory towers trying to understand the molecular basis of lung ventilation in the name of patient safety that we have failed to see the soul of anesthesiology is being hijacked by the nurses.  While the AANA is cranking out multiple papers per year on why they are at least equivalent to MDAs for less cost, we haven't produced a study demonstrating the value of anesthesiologists in today's health care environment.  The nurses only need to prove they provide care as well as doctors to have an advantage, because if all else being equal, the deciding factor will be cost, their ultimate trump card.  If that situation should come to pass, the only way we anesthesiologists can stay gainfully employed is if we lower ourselves to an equivalent salary.  That will indeed be a sad day for anesthesiology.