Wednesday, April 7, 2021

CRNA's Take Over Wisconsin Hospital

No anesthesiologists work here.

This is the type of news that makes anesthesiologists' blood run cold. Watertown Regional Medical Center in Wisconsin has removed all their anesthesiologists and replaced them with CRNA's. Wisconsin is one of the states that allows CRNA's to work without physician supervision. Therefore they can practice independently without even a surgeon supervising them. How does this cost cutting move by the hospital make the surgeons feel? In a decidedly indifferent comment, Adam Dachman, DO, a surgeon at Watertown, said, "It's a misconception that physicians are required to administer anesthesia." Ouch. Thanks for standing up for physician brotherhood.

This attitude is what I was afraid of when I said the anesthesia care team model will be the end of physician anesthesiologists. With the ACT model, anesthesiologists' roles become more like physician assistants. We're outside the operating rooms, dealing with preop history taking, starting IV's, making sure the patients are ready for their surgeries. Meanwhile, the CRNA's are the ones that are administering the anesthesia. They are the ones the surgeons will interact with 90% of the time. Our interactions with surgeons diminish to the point where they feel the CRNA's are doing all the work and no physician anesthesiologist is needed. This makes the hospital administration's decision to save money by firing all the anesthesiologists that much easier and less controversial with the staff.

The federal government is helping the demise of physician anesthesiologists by allowing the nurses to practice nationwide without supervision. Under the guise of increasing medical access during a pandemic, the CMS is letting CRNA's work independently so physician anesthesiologists can use their critical care skills to treat the maximum number of patients. This provision is supposed to sunset in June as the pandemic eases across the country. Not surprisingly, the AANA has something to say about that. They are talking with the nurse friendly Biden Administration about extending the opt out provision to the end of the year and possibly beyond. 

The coronavirus has been a seismic shift in how medicine is practiced. For anesthesiologists, it may be the final push out the OR doors that we have always feared. 

1 comment:

  1. I think the middle paragraph is accurate, at least in some areas of the country. It is a self inflicted wound by anesthesiologists. The anesthesia care team model with 4:1 Medical Direction is for economic gain, not top quality patient care. If Medicare allowed 6:1 under the billing code for Medical Direction, I believe many practices would go to 6:1. The extrapolation of surgeons interacting with CRNAs 90% of the time and anesthesiologists never in the OR is that, over time, the anesthesiologist may be thought of as incompetent to actually do the case themselves. I witnessed that very thing in a practice where no value was placed on the anesthesiologists ever doing any cases themselves. There were anesthesiologists who hadn't done cases in decades and were thought of as incompetent to do so by the surgeons, the CRNAs and the OR staff! The pathetic thing is that they weren't wrong. I left that practice because I had no professional pride or satisfaction in a practice like that. What is the answer? #1- in a practice that uses CRNAs, the anesthesiologists need to do a significant percentage of cases themselves ( maybe 20% ), skewed toward the more difficult/complicated cases. and #2 when the "Care Team Model is used, 4:1 is a joke-all 7 steps cannot be accomplished and it invites billing fraud. 2:1 or 3:1 is more reasonable and logistically allows the anesthesiologist to actually do more than sign a chart. #3 The above 2 items come at an economic cost, but it is worth it for many reasons.