CRNAs = Anesthesiologists. We Only Have Ourselves To Blame

Sigh.  In another indictment on the worth of anesthesiologists in the operating room, a study in Health Affairs has declared that patients who receive anesthesia from CRNAs are no more likely to suffer a complication than those who are anesthetized by anesthesiologists.  The authors of the report looked at anesthetic complications in states who opted out of Medicare's rule requiring physician oversight of CRNAs vs. states who did not opt out.  They found no differences in the reported rates of deaths or complications from anesthesia.  They also looked at the complication rates before and after states opted out.  Again there were no differences. They only found that anesthesiologists tended to perform more complicated anesthetics, perhaps due to CRNAs doing more work in small rural hospital settings.

For any anesthesiologist who has worked with CRNAs, the results should come as no surprise.  Though we hate to admit it, most of them are every bit as competent as MDAs. I wonder though how much of this equivalency is the result of the evolving nature of anesthesia.  Are anesthesiologists and the ASA, in our relentless pursuit of patient safety, devaluing our own work?  It was not that long ago that the practice of anesthesia was a tedious, tiresome, hands-on drudgery.  Back before automated sphygmomanometers, the anesthesiologist had to crouch under the drapes to measure the blood pressure by listening for distant Korotkoff sounds in a noisy operating room.  Good luck if the patient was hypotensive or the arms were not accessible.  In the days before capnography, anesthesiologists were literally tethered to the patient by a precordial or esophageal stethoscope to ensure the airway was patent.  Nowadays with all the automated monitoring in the operating room, an anesthesiologist is free to walk around the OR to chat up the surgeons and the nurses or just to stretch his legs.

Anesthesia is so safe now that anesthesia attendings feel comfortable leaving a CA 1 resident in the OR by himself to do a case while he goes to another room nearby to teach a different resident.  The safety profile of anesthesia is so high that it takes thousands of cases to find any meaningful rates of complications.  Take for instance the recent quick demise of rapacuronium.  The FDA tested this new muscle relaxant on thousands of patients before approving its use. It was not until millions of doses had been given that the FDA realized there were serious side effects of the drug and had it quickly pulled from the market.  Succinylcholine would not stand a chance of approval today.

Is it any wonder that, despite the ASA's demagoguery of CRNAs, their work holds up just as well as anesthesiologists.  I fear it will get more difficult in the future for anesthesiologists to justify our reimbursement levels when we can't prove that our skills are any more valuable than CRNAs', not when technology has leveled the playing field for everybody.