Sunday, May 10, 2015

What Do CRNA's Really Want?

Recently, a bill came up in the California legislature to allow the use of anesthesiologist assistants to practice in this state. Never heard of AA's? Anesthesiologist assistants have a Master of Science in Anesthesia degree and are licensed to work under the direct supervision of an anesthesiologist. They are currently allowed to work in 17 states and the District of Columbia. An AA graduates from training with a minimum of 2,000 hours of clinical work. There are currently about 1,700 AA's working in the country.

The California bill, AB 890, is sponsored by Democratic Assemblyman Sebastian Ridley-Thomas and the California Society of Anesthesiologists. Why does California, or any state, need AA's? To allow greater access to health care, of course. According to Dr. Paul Yost, president of the CSA, "So many more patients are entering the health system and more baby boomers will be needing care."

So who would oppose granting patients increased access to medical care? Ironically, it's CRNA's. Even though their political mantra has always been that CRNA's are needed because there are not enough anesthesiologists available for all the cases that need to be performed, they are angrily opposing the passage of AB 890. There is even an AA opposition letter that is circulating on the web that is very much a rough draft at the moment.

Why would CRNA's be against having more healthcare providers available to take care of patients? Just follow the money. AA's can do everything that CRNA's do, except they are under the supervision of an anesthesiologist. AA's don't have privileges to work independently and they have no desire to do so. They know they are not doctors and would rather have an MD take the responsibility of making critical decisions in patient care. They are here to help the anesthesiologist, not supplant them.

CRNA's, on the other hand, wish to act and be treated like physicians. They want to work without anesthesiologists looking over their shoulders, even though their level of training is far below what most anesthesiologists would consider adequate for independent practice. If AA's are allowed to work in the biggest state in the country, they will severely hinder the expansionist agenda of CRNA's. If anesthesiologist assistants can work the same cases as CRNA's, but with the built in safety net of an experienced anesthesiologist present, why wouldn't you want to hire more AA's? This is where the nurse anesthetists are going to have to show their true colors. Who are they really advocates for, patients or CRNA's?


  1. We have got similar problems in Nigeria. The anaesthetic nurses wish to be treated like physicians. Their qualifications are far below those of anaesthesiologists yet they want to run cases independently.

  2. As a practicing CRNA in California, I too am at odds with the stance that my state professional organization is taking towards this bill. On the one hand, I can see why we'd have to take the policy position that we're taking. However, on the other hand, and this is one that I have difficulty reconciling, it runs counter to our premise that we provide cost effective, high quality care. As someone who believes in fairness and equal opportunity, it only makes sense that we would want AAs to practice in the state of California, especially if it helps the state expand anesthesia services to areas that are underserved. This should be the position for all parties involved, whether CRNA, MD, or AA.

    Which brings me to a larger point. It is concerning to me that there is this animosity that is festering between the CRNAs and MDs and quite frankly, I do not understand why. I have arguments and complaints from both sides, but these statements I hear are anecdotal at best and completely unsubstantiated. To date, I have yet to come across any kind of data (not biased by our respective professional organizations) that suggests either party provides a safer anesthetic over the other. I'm sure you've read them too. More importantly, I would raise the question, does it matter?

    As you already know, the risk that a patient will suffer an adverse event as a result of anesthesia is minimal, especially if you have an ASA classification of I or II. In the majority of cases, I think it is fair to say, and you may disagree, that the differential diagnoses we most likely face in the OR are confined (but perhaps not limited) to either a bronchospasm, laryngospasm, myocardial infarction, or malignant hyperthermia. To me, this is an affirmation on how safe anesthesia has become; that we are relegated to a handful of potential (and rare) problems that may occur. To say that one is more qualified than the other when the list of problems that might arise within the OR (and we can even include PACU) is specious and not supported by any kind of data other than by anecdote.

    That said, my argument isn't that CRNAs should replace MDs or that AAs should not practice in California. I'm all for everyone practicing anesthesia. I'm sure by now you're noticing I have a Kumbaya kind of approach. Perhaps I'm naive and oversimplifying the politics of anesthesia, but it would seem the best compromise that could accommodate all 3 parties would involve the anesthesia care team model.

    1. "It is concerning to me that there is this animosity that is festering between the CRNAs and MDs and quite frankly, I do not understand why."

      The answer is money and available jobs. It does not make sense to me that as someone going through medical school, residency, and fellowship, (9 years post Bachelor's degree), someone with about a third of this can claim to be as qualified and practice alone. There's the saying that everyone wants to be a doctor, but no one wants to put in the work actually required to do it. This is a prime example.

  3. If you follow the money, then you understand why Anesthesiologists (MDs) are actively pushing down CRNAs. It’s all about the money for everyone involved and AA’s are MDA’s peons in this whole game.

  4. Stating that all CRNAs prefer to work with MDAs is a pervading statement that speaks to the egotistical nature of select physicians, such as yourself, who continually demean the CRNA profession. Secondly, CRNAs can practice independently, thereby increasing access to care, whereas AAs cannot. Therefore, AAs provide no additional benefit to the demand for access to anesthesia services.