Sunday, January 30, 2022

War With CRNA's At The VA

With exquisite timing, right in the middle of National CRNA Week, the president of the American Society of Anesthesiologists sent a blistering email to ASA members lambasting the Veterans Administration for not taking seriously concerns about CRNA's practicing independently.

The Spokesman-Review article that Randall M. Clark, MD, FASA referred to describes attempts by anesthesiologists at the VA hospitals to use a whistleblower program called "Stop the Line" to report unsafe patient care conditions outside the normal chain of command. This is in response to the VA allowing CRNA's to practice independently at the nation's veterans hospitals. 

The anesthesiologists have used "Stop the Line" four times but have received zero response from the department. When news of these reports were discovered, the nurse anesthetists were not terribly happy. They threatened work stoppages and slowdowns in retaliation. 

Predictably the CRNA's are framing this as an access issue. Without their presence, they warn that veterans will have less access to lifesaving surgery and face major delays in care. 

Frankly, I find this latest skirmish between anesthesiologists and CRNA's pointless. If the ASA is trying to prevent CRNA's from practicing independently, that horse left the barn years ago. The Covid pandemic opened the door to the nurses practicing without physician supervision nationwide during the Trump Administration and the nurse-friendly Biden Administration is unlikely to change that. 

Once nurse anesthetists have a taste of independent practice, it is very difficult to force them back into a care team model. It's the same feeling when anesthesia residents finally become attendings--nobody wants to have somebody looking over their shoulder when they've had the opportunity to make their own decisions about patient care without being second-guessed.

At this point, it really is futile to try to return to the care team model where CRNA's have already practiced independently. The best outcome for the ASA is a tenuous detente where we maintain the physician supervision that is still in place and attempt to not lose any more ground. 


  1. Go on the attack instead of being defensive. Otherwise this field will die.

  2. I have practiced in an all physician practice, a care team model practice and in sort of a hybrid, the latter as a locums.The care team model is a joke. Because of the economics of reimbursement, in a care team model practice, there is an inexorable push to 4:1. With that ratio, the anesthesiologist is largely relegated to being a chart signer, frequently not adding any real value to the case. In a busy 4:1 practice, it becomes logistically impossible to fulfill all 7 steps of medical direction & keep the workflow moving. I believe many such cases are billed as medically directed even if all 7 steps were not met, constituting fraud. I have seen anesthesiologists in a practice like that who hadn't done a case themselves in decades and were afraid to !!!! Disgraceful! The hybrid ( parallel ) practice had anesthesiologists & CRNAs, each just did their own cases & were billed as either AA or QZ. No anesthesiologist "medically directed" or "supervised " a CRNA & therefore the hospital assumed professional liability exposure for the CRNA, not the physician. I personally think my time & expertise were much better utilized doing cases myself in the heart room rather than going from room to room watching CRNAs insert LMAs and signing the chart.