Nurses are an equal, if not superior choice, to administer anesthesia |

Apr 18th
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Nurses are an equal, if not superior choice, to administer anesthesia


Unlike so many others in the health care policy arena who find themselves concerned with bottom lines, gored oxen and political consequences, my job as President and CEO of the New Jersey Health Care Quality Institute is a relatively easy one. I have a clear focus: health care quality and patient safety.

So when the Institute was asked to weigh in on the issue of whether New Jersey Advanced Practice Nurse Anesthetists should remain the only Advanced Practice Nurses required to have the presence or direct supervision of a physician certified in their specialty (Anesthesiologists), we did not hesitate. The clear answer from a patient safety point of view is unequivocally "No." The cause of health care quality is not advanced by requiring supervision and may, in fact, be harmed. In my view patient safety is the only issue that should matter in this increasingly heated issue exchange.

It is important to understand the history of anesthesiology in America to fully comprehend this issue and why nurses are an equal, if not superior choice, medically for this procedure. As I testified before the Department of Health and Senior Services Health Care Administration Board which correctly advanced regulations eliminating the supervision requirement, the very first professional that provided dedicated coverage to a patient under anesthesia was a nurse. That was more than 125 years ago. Physicians did not follow until some three decades later. Since that time, nurse anesthetists have grown to providing more than 25 million anesthesia applications annually with a safety record of which nearly every medical professional would be proud.

In fact, this is not even a close call when it comes to patient safety. Every peer-reviewed study that has ever been conducted on the issue — and there have been many — has reached the same conclusion. Nurse Anesthetists have performed at the same level of Anesthesiologists or better than Anesthesiologists. It's a safe record and in the field of health care quality, where there are so many failures in this nation for which we should be ashamed, this is one to be admired.

I will cite just one of the studies not only because it is the most recent, but because it is also the most comprehensive and the most compelling. The study was published in the August 2010 issue of Health Affairs and it says everything one needs to know just by its title, "No Harm Found When Nurse Anesthetists Work Without Supervision by Physicians." The study examined nearly 500,000 individual cases and confirms what previous studies have clearly demonstrated: Advanced Practice Nurse Anesthetists provide safe, high-quality care. The study also shows the quality of care administered is optimal, regardless of whether physician supervision is conducted or not.

This most recent study followed up on a Federal government decision in 2001 that permitted states to "opt out" of the Medicare physician supervision requirement for Nurse Anesthetists. Since this option was offered, 16 states — most recently Colorado this past September — have opted out. The study concluded that the Medicare physician supervision rule is obsolete and unnecessary. In fact, one of the study's authors, Jerry Cromwell, PhD, said "We find no evidence that opting out of the oversight requirement harms patients in any way."

And there is an objective approach to assess this risk. As imperfect as the medical malpractice insurance system is, it is still a good gauge of risk and dangers. It is interesting to note that the average New Jersey physician Anesthesiologist's malpractice rate ranges from $14,124 to $31,843 annually. Compare that to the $120,198 to $197,425 range for OB/GYN's. This difference in rates demonstrates that an OB/GYN has at least six and up to 16 times the risk of an Anesthesiologist.

Interestingly enough, Certified Nurse Midwives, who have similar degree and licensure requirements as Nurse Anesthetists, may practice and treat patients independently. These Midwives work unsupervised in both hospital Labor & Delivery units as well as free-standing birthing centers. It seems counterintuitive to require a physician to be present to directly supervise a Nurse Anesthetist's care while no such oversight is deemed necessary for Nurse Midwives given that both nursing specialties have an excellent safety record and Nurse Anesthetists have between six and 16 times less risk involved in the care they provide. Additionally, while Nurse Midwives often practice on their own with no physician present or even nearby, Nurse Anesthetists never practice without a physician present and part of their team. Further, the current Advanced Practice Nursing rules require collaboration by a physician with all of their protocols and medications before they can be administered. Requiring the unnecessary, duplicative and costly presence of an Anesthesiologist to supervise an Advanced Practice Nurse Anesthetists makes no sense whatsoever.

New Jersey should do the right thing and take the course that leads to better health care quality outcomes. The Commissioner of Health & Senior Services should ignore the distracting, economically-motivated arguments on this issue and focus only on quality, safety and the health of the patient. That path is clear; Advanced Practice Nurse Anesthetists should be treated as all other Advanced Practice Nurses and should not be required to have an Anesthesiologist present for the safe delivery of their care.

David L. Knowlton, President and CEO of the New Jersey Health Care Quality Institute headquartered in West Trenton, is a former Deputy Commissioner of Health during the administration of Governor Tom Kean.

Comments (57)
57 Sunday, 08 December 2013 20:49
Lets face it nurses, you are nurses not Doctors. If you wanted to be a doctor, then go to medical school. Didn't get accepted? Oh really - too bad - we made the cut because we are more intelligent! Who would you rather have at the head of the table? I think I would rather have the more intelligent person, not the one who could not make the cut - B team material.
56 Monday, 15 April 2013 14:46
The study in Health Affairs that nurses keep citing is an incredibly poor measure to change policy that will effect millions of peopels. The study looked at medicare billing data over a 7 yr period. The study excluded patients with more than one hospitaliztion during a quarter and procedures that occured in ambulatory surgery centers (were you will find most of your CRNA solo practices). The 7 yrs included 741,518 surgical discharges. One third did not of anesthetic claims because they were likely procedures such as PCI, pacemaker lead placement, bronchosopy, etc that did not require an anesthetic. The other decided to exclude the vast majority of those no anesthetic provided surgical cases except for the ones provided in a rural pass through hospital in which they were placed in solo CRNA group. After the exclusion the author had 481, 440 surgical discharges. Of which 412, 696 occured in non op out states were CRNAs are required to be supervised by a physician. 68, 744 occured in opt out states were CRNA did not have to be supervised by a physician. Of the 68, 744...41,868 occured before opt out was passed into law. Thus, only 26, 876 of the 481,440 surgical discharges were performed by solo CRNAs which included the cases were no anesthetic was likely even performed in rural pass through states. So to start this study is invalidated just by looking at numbers alone considering the risk of anesthetic mortality is around 1:500,000 surgical cases and the study only looked at 26, 876 surgical cases performed by a non-supervised CRNA. But even more suprising is that the study showed that anesthesiologist working solo took care of patients who were considerably more ill with expected increase in motality of 7% based on this finding but the data showed mortalities to be the same between anesthesiologist and CRNAs. So in summary CRNAs who work solo provide very few anesthetics in opt out states compared to the team model or solo anesthesiologist practices and even though they perform anesthetics for simpler procedures they have a similar mortality rate. Hmmm who do I want providing my anesthetic....a physician or a nurse.
55 Monday, 25 March 2013 19:00
As the other post stated an anesthesiologist is a physician. What they are incorrect about is a Anesthetist is a advanced practice registered nurse, someone who holds a bachelors degree in nursing, and in most instances a masters degree in anesthesia. The first well know Anesthetist began practicing in 1887, although the first official anesthetist school did not opened its doors until 1909.
Many studies have proven the safety of advanced practice registered nurses and more specifically anesthetist. The most recent study was released in 2010 showing, in almost 500,000 cases, there was no difference in safety whether an anesthetist practiced alone, an anesthesiologist practiced alone or when they worked in conjunction.
In 2010 the institute of medicine recommended removing unnecessary regulatory and policy barriers allowing all health practitioners to practice to the fullest extent of their education.
54 Monday, 21 January 2013 15:36
concerned consumer
Thanks to the internet, the consumer will be well informed in the future. Once everyone asks "are you an MD or a CRNA?" and finds out no anesthesiologists are employed by this center, they will hop out of bed and sprint to the front door (or have a family member wheel them out). The CRNA misinformation spread through the internet will see its downfall caused by... the internet.
53 Wednesday, 16 January 2013 21:04
Thomas A. CRNA
Have been in private practice since 1982. Pioneered office based anesthesia back in 1982 and currently have 15 CRNAs performing 20,000 office based anesthetics per year...415,000 cases in total thus far and we have a pristine unblemished record of patient safety. Anesthesiologists should remember it is they who entered a nursing profession...anesthesia has been delivered by nurses since the late 1890s. CRNAs organized their certifying board in 1933 and anesthesiologists formed theirs, the ASA, in 1955...just saying time to get the facts straight. If MD anesthesiologists have egos that don't permit them to accept historical fact maybe they should have chosen a field of medicine and not nursing(anesthesia). Additionally CRNAs, as the anesthesia cost /safety leaders, will only grow stronger as their MD anesthesia imitators are priced right out the door...its happaning all over the country...have you heard of the new national groups, EmCare, NAPA, etc...have you seen their staffing models . Sayonara MDAs !!!
52 Tuesday, 04 December 2012 22:41
Equating the scope of an anesthesiologist (a physician with umpteen years of med school, residency, specialty residency etc)..with that of a CRNA-an RN with 20 months of nurse anesthetist absurd. I have been on both sides, first as a nurse then as a student physician. There is no comparison..a crna is a trained nurse, an anesthesiologist is a physician highly trained in a demanding profession-anesthesiology. Do you want a crna (a nurse, yes I was one) managing your case when something goes wrong or a highly trained physician (an anesthesiologist)?
51 Saturday, 10 November 2012 05:05
Luke B
Bottom line... look at the research. Unless you've conducted a study involving more than the 500k cases mentioned above your opinion wastes my time and demonstrates insecurity. Simply laugh on your way to the bank knowing you make 3x as much as a CRNA for doing the exact same job. Often less.
50 Friday, 31 August 2012 15:42
Concerned MD
The concept of equating a nurse anesthetist with an MD/board certified anesthesiologist is an absurd one. Where else in the world do you see health care systems being so callous as to allow nurses to administer potentially dangerous anesthetic medications and to independently manage a patient under general anesthesia? Sure, any idiot can learn how to push propofol and to intubate for an appendectomy or hernia repair. But who knows how to manage the ventricular tachycardia that might occur during induction or the specific set of anesthetic considerations encountered in a rheumatoid arthirits patient who has cervical spondylosis, pulmonary nodules, pericarditis and secondary amyloidosis induced renal dysfunction? My point is this; let the people with the necessary knowledge base and skill set do the job they have trained for over a decade to do. If the US had more MD anesthesiologists, this travesty of nurses with practicing priviliges would never have occured.Honestly, I feel exceedingly lucky knowing that when I eventually become a patient I won't have a substandard, undereducated, ill suited healthcare provider taking care of me in the operating theatre because in my part of the world we still strive to deliver the very best of care to sick people... Please stop fooling yourselves, you are who you are. Accept your limitations and learn to work within them and don't let your egos compromise patient care and safety.
Anaesthetist - UK
July 10, 2012 | 3:02 pm
Your comment is awaiting moderation.
I have been following this fascinating, yet highly polarised debate for some time.
Firstly, as an Anaesthetist i trained 5 years in medical school. 2 years in medicine, surgery and ‘ER’ medicine. Then to become fully solo anaesthesia provider – a Consultant Anaesthetist takes a further 7 years, Ct1 to ST 7.
Secondly, the study carried out was hardly level 1 a evidence. In medicine, a large, multi centred, double blinded prospective study is considered far superior to the one carried out, for political and economical gains by the AANA. If truly one wanted to delineate a difference, then patients should be blinded as to have solo nurse vs physician. Encompassing all patients ASA1-4, from hernias to liver and heart transplants.
Thirdly, one can argue nurses historically carried out anaesthesia, this was the case when anaesthesia was not an established independent speciality and mortality was incredibly high, almost 20% by 50′s
- Bunker JP. Historical aspects. In: Lunn JN, ed. Epidemiology in Anaesthesia. London: Edward Arnold, 1986; 1–7
-Commission on Anaesthetics. Report of the Lancet Commission appointed to investigate the subject of the administration of chloroform and other anaesthetics from a clinical standpoint. Lancet 1893; 1: 629–38, 693–708, 761–76, 889–914, 971–8, 1111–8, 1236–40, 1479–98
- Waters RM. The evolution of anesthesia I and II. Proceedings of the Staff Meetings of the Mayo Clinic 1942; 17: 428–40
- Beecher HK, Todd DP. A study of the deaths associated with anaesthesia and surgery based on a study of 599,348 anesthesias in 10 institutions 1948–1952 inclusive. Ann Surg 1954; 140: 2–35
I believe in a time when patient safety is paramount, i can not fathom why such arguments are being made. Why not let physiotherapist conduct thoracotomies? Dieticians medically manage Crohns.
Using anaesthetic drugs is not joke, and the manufacturer, astrazenica recommends that only ‘those trained in general anaesthesia and advanced airway skills’ prescribe the drug.
Finally, i the UK, the salary of us doctors are fixed. In other words, in the NHS, the base salary is fixed, regardless of number of patients anaesthetised. The prescription and administration of propfol and other potent anaesthetic agents by non airway trained /anaesthesia doctors is off label and thus highly controversial. Also, nurse anaesthetist are not generally left solo with any patient undergoing general anaesthesia. The exception being Physician Assistants Anaesthesia – the idea was flirted with several years back, however, was proven to be a bad idea.
I thus propose that if anaesthesia can be provided by non-physicians, then please provide the proof in the form of level 1 A evidence.
48 Tuesday, 05 June 2012 11:34
I work for a hospital that has a mix of crnas and anesthesiologists. The care provided by the anesthesiologist is clearly superior. First of all, crnas have a harder time placing endotracheal tubes, arterial lines and central lines. The anesthesia guys make it look effertless just because they have done it a million times. The crnas have to frequently call anesthesia for help becuase they cant do something, or becuase the patient is unstable and they cant figure out why. In reality, they are just nurses without an indept knowledge of the human body. They know what to do by experience, but they dont know why they are doing it. They frequently just fix fital signs with pressors without addressing the unerlying cause. They slow down the operating room because it takes them more time to assess the patient, to put the patient to sleep, and to wake them up. They are very bad at regional anesthesia and end up putting brething tubes for all patients even if its not necessary and could be easily avoided. They flat out lie to patients, and never tell the patient that they are just a nurse. They always say "i'm from anesthesia" and never clearly identify themselves as a nurse. Unfortunately a lot of patients dont know better. I would NEVER get my anesthesia from a nurse. Anesthesia is safe because the doctors spent 8 years of their life training for it, compared to 2.5 years spent by the nurse. Dont be fooled by the studies you see, the nurse always get the easy case and healthy patient. The doctor gets the 90 year old with a bad heart. Thats why their data looks similar. If nurses took care of sick patients, i truly believe more people would die on the table. If you care about yourself or your loved ones, as for a DOCTOR to take care of them when it really counts. Dont let these politicians fool you because they want to save money. Its your life on the line.
47 Wednesday, 07 March 2012 09:02
Patient care
2 questions: "Do anesthesiologists ever have to bail out CRNA"? answer: YES. SECOND QUESTION: " Is anesthesia delivered by an CRNA working solo or supervised by an anesthesiologist just as safe as anesthesia delivered opersonally by an anesthesiologist? No, it's not. CRNA may think it's close, that's their opinion. Dirty little secret: you have the right to demand anesthesiologist-only care despite what the CRNA may try to tell you; ask in advance and speak to the head of the anesthesia department. Anesthesia can be safe; patients don;t usually die on the table anymore. But many suffer unecessary pain, PTSD and POCD because a nurse (CRNA) can't recogzine the subltle issues that develop requiring medical intervention. Also: the CRNA stats are bogus....when an anesthesiologist bails out a CRNA it's never recorded anywhere........
46 Thursday, 05 January 2012 22:29
I have seen an increase among educated, medically sophisticated patients who refuse to have their anesthesia administered by a nurse (crna). They want an anesthesiologist because of their superior training and skill set. Question: do anesthesiologists have to bail out crna? answer: every day. Why would a thinking person want a crna, especially one working solo? Just because anesthesia has become quite safe doesn't mean that nurses should administer it.
45 Saturday, 16 July 2011 17:33
I have worked in both the team care and independent model. There are both MDs and CRNAs who are bad apples. Vigilance and continued education coupled with experience are the ingredients for maximizing good patient outcomes no matter what initials trail your name. Keep in mind, that when the shiit hits the fan, many times it's because of the inept (but nonetheless, MD) surgeon at the other end of the scalpel who creates such a scenario. Also, I have worked with many surgeons who 'ship out' a very complex case. So, MDs as well as CRNAs have their limits and know when to 'ship out', request further consultation, etc. It's those who don't know when to 'ship out' or request further consultation that you should be afraid of. For every 'bad CRNA situation' that you all have mentioned, I can match it with a 'bad anesthesiologist situation.' I have worked as a locums CRNA and have had medical students assigned to me. Their in depth knowledge of minutia ('manure-tia') such as Krebs cycle, all the other liver pathways, origins and insertions of all the muscles, all the completely USELESS when it comes to anesthesia. How many experienced anesthesiologists can even recall all that detailed 'book work' that eventually lead to their MD degree? Not many if any at all! You might do well on Medical Jeopardy with that knowledge, but it doesn't make you a superior anesthesia provider. Vigilance, attention to detail, continued education, and experience without a doubt are crucial to every anesthesia provider.
44 Wednesday, 23 March 2011 18:25
I can only say that the last person in a medical class can still hold his/her head high as there no other profession with students as competitive and bright to get a place in the class.
many crna schools are factories and you only need a pulse and check book to get in. they graduate people who barely got thru community college.
to be honest, there is a lot of anesthesia that is not difficult. the problem is that the crnas do not have the training or experience to deal with many of the disease systems (pathology) because they don't have the educational background and skills that comes with 8-10 yrs of post graduate education/training. this is not to say that a very bright and skilled crna comes along that shouldn't have gone to medical school but for whatever reason didn't. i'm just stating that there isn't a week that goes by that i don't have to bail out a crna.
43 Wednesday, 23 March 2011 18:10
James E Tylke, MD
This is why CRNAs are being replaced by Anesthesia Assistants. They are overpaid physician extenders who incorrectly believe they are part of the solution when they are really self-indulgent technicians that are trying to practice medicine without a license.
42 Wednesday, 23 March 2011 13:07
Hell, let's just let the flight attendants fly the plane............I'll take the train thank you.
41 Wednesday, 23 March 2011 13:06
Hell, let's just let the flight attendants fly the plane............I'll take the train thank you.
40 Sunday, 13 February 2011 23:16
to RJB
RJB, you say to get the facts and do the research.. how about simply scrolling up to the very top of this webpage and READ the advertisement. I'm sorry, but you now have lost all credibility, just like most of your collegues in this forum.

2 links for ONLINE CRNA and DNP degrees...

"Nurse Anesthetist Degree
Get Free Info on Nurse Anesthetist Degrees at Top Online Universities."

"Online DNP
Online Doctor of Nursing Practice BSN or MSN to DNP tracks."

too easy.
39 Friday, 11 February 2011 03:28
Get your CRNA degree online? Currently, you don't have to have a bachelor's degree to become a CRNA? These are clearly and blatantly false statements. Do some more research, outside of the SDN webpage and find some factual information... oh and the Doctor of Nursing Practice is not claiming to be a physician, but rather a DOCTOR. Don't you know some one with a PhD? You know, like the people that educated you in college, that you referred to as "Doctor So-and-so." How about Doctors of Physical Therapy? How about a Pharm.D? Yes, they are doctors.... do they think they are PHYSICIANS, nope. Neither does the DNP.
38 Tuesday, 08 February 2011 10:27
spin it however you want.. but it boils down to one simple question to the consumer, to the public..

Who do you want administering you or your loved ones anesthesia, a doctor or a nurse?... answer.. too easy. nuff said.

keep spinning.
37 Tuesday, 08 February 2011 10:09
you are all retarded..go back to work and get some new hobbies
36 Sunday, 06 February 2011 20:47
I currently have a colleague who is ABA certified. He has had several "mishaps" involving patients. Blood loss unrecognized and untreated. Hypothermia. Failed blocks. Prolonged hypoxia on emergence. Another ABA certified colleague who allowed ST segment depression to go untreated. Did not arrange follow up for the patient post op. Fortunately I practice independently. What would I do if they were supervising me? Well I would be practicing independently. Wake up folks. Despite your so called extensive training in all aspects of medicine there are still people out there who are weak anesthesia practitioners. I am held to the same standards as any physician anesthetist. I read the same journals refer to the same text books. I have an advanced degree in human physiology where the same text was used by the affliliate medical school. Unfortunately we will never resolve this issue. If reimbursement went away I think much of the heated debate would fade away. For now we should treat each other better. Hopefully we just want what is best for our patients.
35 Friday, 04 February 2011 08:20
Steve CRNA
The issue is, and continues to be, economic. No studies have demonstrated you are safer with a CRNA or MD providing your anesthetic. No surgeon is better protected from liability working with a CRNA or MD, it relates to the surgeon's participation in the anesthetic. What does a MD do when they need help with a patient? They ask for a Consult. A CRNA would do the same since any professional should recognize when a complex issue demands the best input available to the provider. Very little room for egos when the precious life in front of us needs attention. Why is it any different in the OR than the rest of the facility? If CRNAs were truly the "weak sisters" most of the posts above purport, then surely the litigation would prove this out. It doesn't. As far as education, I have 4+2+2 years, equals 8 years. CRNAs have completed over 1,000 cases of all types before graduation, also have been observed by all manner of providers CRNA and MD, before graduating. ONLINE CRNA? are you serious doctor? where, doctor, did you learn of this? Does not exist. What does exist is a myriad of different medical schools in all parts of the globe, many with different learning experiences than is gleaned here in the USA. Also, relating to training, when you participated in your three month surgery rotation, how many gallbladders did you take out? or did you mostly hold a retractor? The point is: most clinical skills are refined during practice, and if they aren't, the individual doesn't participate in those activities. To repeat, the studies simply don't demonstrate the Nurse Anesthesia practice is less safe than Physician Anesthesia practice. It's about the money, and control of credentialing committees, restricting practice of CRNAs, and protecting turf by an aggressive lobbying effort.
34 Tuesday, 25 January 2011 14:42
CRNAs are ALL board certified!... But shouldn't you look at what board certification really means?? Just review their board cerification process (and make note of their entire, post graduate training) see the thread below. It is a joke. They love standing behind 'we are all board certified!' .... "Hey guys listen, if we automatically board certify all us, then it looks like we're more legit than those non-board certified anesthesiologists".

But, come on!.. really? Can you seriously be proud and stand behind your board certification process as holding a high standard?.. Do I need to review the numbers again... 175 total multiple choice questions (RN+CRNA board exams). How do you think the public would view these numbers? It's only a matter of time until the smoke clears and patients will know the difference.

175 questions, representing the 'board certified CRNA'. It doesn't even equate to the first USMLE (United States Medical Licensing Exam) that medical students must take and pass after their 2nd year of medical school!!!!!!

There are some Anesthesiologists who are not board certified. However, most hospitals and private practice groups require board certification for their MDs, and patients do have the choice to have a board certified MD if they want it. Even still, I'd rather have a board-eligible anesthesiologist put me to sleep than a 'board certified' crna, based simply on the drastic differences in the training process and that one is a licensed physician who went thru 12-14 yrs of rigorous training, including 4 years of residency, being held to the highest academic and clinical criteria.. and the other is a nurse who went to anesthesia school. The ABA doesn't go around willy nilly board certifying physicians, nor does any other physician specialty. Physicians actually have standards that have legitimate meaning behind the word 'board certified'. That is what the patients demand and that is what they should receive.
33 Monday, 17 January 2011 19:32
Your response to my post does nothing to disprove the facts that I listed regarding the education and testing requirements of the two providers. You only make an assumption of who I am, and bash an entire forum that I may or may not be associated with. However, there is nothing that you can say regarding my points because they are facts that cannot be refuted or "spun" no matter how hard one may try.

I, too, am in favor of a collaborative model where both providers can work together for the overall good of the patient, but we both know that there are providers on both sides of the fence that are not in favor of this stance. Moreover, I do agree that Medicare fraud is a problem, and I am sure that both anesthesiologists and independent nurse anesthetists have manipulated the system in the past to their benefit.

I am sure that the analogous nursing forum is a beacon of light for all humanity and certainly not a “bastion of character assignation, insults, vitriol, misinformation, fear mongering, and propaganda.”

I am also certain that a nurse anesthetist would not “actively deceive the public for their own benefit”, such as the times I’ve seen a CRNA be called “Dr.” by a patient with no correction being made by the CRNA or how some advanced nurses will get their DNP and introduce themselves as “Dr. Smith” to patients, knowing that with the introduction of that title a patient thinks you are a Doctor of Medicine instead of a Doctor of Nursing Practice. And let’s not mention the “journal articles” such as the one being used in this author’s commentary that are sponsored by the AANA. Certainly, there is no bias in the reporting of data and results in those “studies.” It's shocking that it didn’t get published in Science or Nature.

And certainly, no nurse anesthetist would “fall so low to use tactics to minimize another group of healthcare professionals” who aim to serve our public. This is clearly demonstrated by the vigor with which some CRNA’s bash Anesthesiologist Assistants (AA’s) and their qualifications to do the job they are trained to do. “Tactics” such as trying to block legislation to open AA schools across the nation would certainly not be attempted by our great country’s nurse anesthetists.

However, I do agree that autonomous and collaborative practices will continue to thrive. Unfortunately for us and the general population, Mr. Deutsch, not everyone shares that same sentiment.

Warmest regards to you as well, sir.
32 Monday, 17 January 2011 18:44
Wendell Spencer, CRNA/MHS
Many patients in my groups care (CRNA only) have saved many lives just like any MDA worth his salt has reflect upon the poor outcomes of one provider vs. another along with the obvious PLANTS in this discussion is a waste of time and energy. Practice should be driven by quality and competency...not ridiculous language that seeks to destroy one profession or another...CRNA's are NOT any less because they chose to provide nurse anesthesia fact the quality outcomes are quite excellent from both MDA providers and CRNA' wonderful that someone refuses to look at the peer reviewed facts....CRNA's provided great care in this country long before anesthesiologists since the late take your banter somewhere else...I have patients to take care of mine.....
31 Monday, 17 January 2011 00:42
Jonathan Deutsch
Sir, likely you are one of the residents from the anesthesiology forum of the Student Doctor Network. Facts, for you, are how you spin them. And you continue a legacy of misinformation. Thankfully, those with objectivity...usually those who are not CRNAs or anesthesiologists...favor working together, respectfully - not unwarranted supervision rules which allow individuals to manipulate insurance companies into paying them for work they are not present for. Yes, Medicare Fraud - I witness it every day. It's sad. And yet, no one on your forum acknowledges this well known fact in the anesthesia community. Your community is not only not helping the public - your actively deceiving them for your own benefit. The SDN forum is a public example of physicians whose dedication to patients has turned into open hatred of any healthcare provider other than themselves.

The anesthesiology forum on SDN has truly become a bastion of character assignation, insults, vitriol, misinformation, fear mongering, and propaganda. - CLEARLY demonstrated in the comments on this article.

It is a sad state when your profession has fallen so low to use such tactics to minimize another group of healthcare professionals in this manner.
Meanwhile, autonomous/collaborative practices will continue to thrive.

Best regards -

30 Monday, 17 January 2011 00:28
Jonathan Deutsch

There were two in that thread, actually. And others on that site. If you think the idea is isolated, you're mistaken. Time will tell.
29 Monday, 17 January 2011 00:02
The comparison regarding the nurse midwife is ridiculous. If there is a complication during the delivery, a physician (OB-GYN) knows how to effectively treat and manage the complication because of their medical education and training. Let that baby be in a breech presentation or have life-threatening decelerations. I would like to see that same midwife pick up the scapel and perform an emergency C-section in the operating room. They cannot do it.
28 Sunday, 16 January 2011 23:44
Facts are facts. Anesthesiologists are physicians first and foremost who have during the course of their medical education and training actually participated in a surgery, delivered a baby, treated a critically ill neonate, learned how to read an MRI, looked at slides under a microscope and learned the pathology, and treated patients with severe heart disease and uncontrolled diabetes. An Anesthesiologist took the same medical school courses and specialty rotations as the esteemed surgeon who is performing your high-risk surgery. After medical school, one chose to be an Anesthesiologist and the other chose to be a surgeon. As a patient, would you want an advanced practice nurse performing your surgery or a physician? It baffles me that the same question needs to be asked when it pertains to the delivery of your anesthesia. Make sure a physician Anesthesiologist is involved with your care every time. Your life can depend on it. There is a place in our country for the care team model under the direction of an Anesthesiologist. Independent nurse anesthetist practice without an Anesthesiologist involved in patient care is setting Americans up for failure and is giving them less than they deserve in this great country.

A lot of people try to make this argument seem like it is all about patient care and safety and cost savings. Let’s stop lying to ourselves. It is about entitlement and money. For an appendectomy, the reimbursement paid for the anesthesia for that surgery from the insurance company is the same whether a physician anesthesiologist or a nurse anesthetist bills for it. The physician may get a bigger cut than the nurse anesthetist does depending on how the money is divided in their group practice after the patient pays but the amount that the patient has to pay on their bill for the service is exactly the same no matter who does the billing. There is NO cost savings to the patient at all. There are some nurse anesthetists who think they can do what an anesthesiologist does because they can start an IV, sit in the operating room by themselves and push some drugs through a syringe. As such, they expect to be compensated like a physician. There is so much more to the practice of Anesthesiology than that. Anesthesiology is the practice of medicine just as every other medical specialty is. Unfortunately, those who are not physicians and don’t understand what the practice of medicine is will never appreciate and understand that fact. Patients should not have to be the ones who find out the hard way that there is indeed a difference.
27 Sunday, 16 January 2011 23:42
There are many opinions but these are the facts:

Anesthesiologists (physicians) must complete a 4 year pre-med college curriculum making stellar grades, take the extremely difficult MCAT test to get into medical school, and complete 4 years of medical school. During medical school, they learn all aspects of medicine and do hands-on rotations during medical school in every medical specialty including surgery, ob-gyn, pediatrics, internal medicine, and critical care just to name a few. They earn a professional M.D. degree after this time. Then they complete a 4 year residency in anesthesiology, including a 1 year internship in medicine, surgery, or a combination of both. Some even do an additional 1-2 year fellowship in anesthesiology sub-specialties, such as cardiothoracic, pediatric, regional, pain, or critical care to further specialize their training in the specialty.

Total years of education to become an anesthesiologist= 12-14 years

Approximately 50% of CRNAs (nurse anesthetists) do NOT have a 4 yr bachelor degree, but rather a 2 yr RN degree. They then go on to complete 2 yrs of nurse anesthesia school (master’s level degree). Many states do not even require that a CRNA have the master’s degree, and in the states that do require it, there are clauses that 'grandfather' in the older CRNAs with only the 2 yr RN and 2 yr nurse anesthesia school. These particular states also vary with the cutoff date, with some states even grandfathering in these CRNAs back to 2003. Additionally, SRNA’s (student nurse anesthetists) rely heavily on Anesthesiologists (physicians) to teach them during the clinical portions of their 2 year nurse anesthesia school education.

Total years of education to become a nurse anesthetist= 4-6 years

To become a CRNA (nurse anesthetist) there are only 2 board exams to pass.

Upon completion of nursing school, the applicants sits for the NCLEX board exam and must pass it to receive the 'RN' or 'BSN' (bachelor’s level degree). This board exam is only 75 multiple choice questions with FIVE hours to complete it. The applicant can fail and retake this exam an infinite number of times.
NCE (National Certification Examination) is the second and final exam to take upon completion of nurse anesthesia school. This test is only 100 multiple choice questions with 3 hours to complete. After this test, a CRNA says that they are “board certified.”

Total number of board questions to become a CRNA= 175 multiple choice questions.

To become an Anesthesiologist (M.D., physician) there are 6 board exams to pass.

To first become a licenced Medical Doctor, you must sit for and pass a series of exams called the United States Medical Licensing Exams (3 exams or 'Steps').

Step 1: taken upon completion of year 2 in medical school. 8 hour exam, 350 questions.
Step 2 CK (clinical knowledge): taken upon completion of year 3 in medical school. 9 hour exam, 370 questions.
Step 2 CS (clinical skills): also taken upon completion of year 3 in medical school. 8 hours, 12 live patient encounters.
Step 3, 2 days: taken during Internship (first year of residency). Day one, 8 hours 336 questions. Day two, 4 hours 144 questions.

In most cases, failure to pass Step 1 or Step 2 results in the medical student getting dismissed from the medical school and that person never becoming a physician in any specialty. If the applicant fails to pass all 3 Steps in a 7 yr period, he or she will not become a licensed physician.

The American Board of Anesthesiology (2 exams)
Part 1: Written Boards: taken upon completion of 4 years of Anesthesia Residency, 4 hours, 250 questions.
Part 2: Oral Boards: taken upon successfully passing the written boards, Two 35 minute oral exams.

Total number of board questions to become a board certified anesthesiologist= 1450, in addition to over 9 hours of demonstrating clinical skills and answering oral board questions and case scenarios.


The recertification process is completely different. CRNAs do NOT have to take another board exam for the rest of their life. All they have to do is 'recertify' every 2 years. By 'recertify', all they have to do is prove to the AANA that they have completed 40 hours of CME (continuing medical education) in a 2 year period. Only 20 hrs/year of continuing education that can easily be accomplished during a weekend course or with a couple of online powerpoint presentations.

On the other hand, Anesthesiologists have to average approximately 50 CME hours every year, complete case evaluations, complete a hands-on simulation course which demonstrates valuable crisis management techniques, and take another written board exam (4 hours 200 questions) every 7-10 years to be able to continue practicing as a “board certified” Anesthesiologist.
26 Sunday, 16 January 2011 23:36
Jim D MD
In response to Jonathan Deutsch and his thread, there is only one MD in the thread who opines that 'independent practice is the future'. Do not misrepresent this as "professionals" who believe this; other than some of the CRNAs on that thread (some do not support this notion).
Really bad example to choose.
Most anesthesiologists do not believe this.
25 Sunday, 16 January 2011 22:29
Jose Jalapeno
I believe the author of this article along with Art Zwerling must be on crack in order to make the above statements.
24 Sunday, 16 January 2011 21:13
Jonathan Deutsch
1. You know little about what CRNAs are educated on, clearly.

2. Art Zwerling's record speaks for itself. His career exemplifies openness and integrity. He practices is the OR everyday. He does not waste time bashing other professions, and nether will I.

Autonomous practices are the future. If you don't believe me, ask the professionals - CRNAs and anesthesiologists - who say so.
23 Sunday, 16 January 2011 19:09
Dr. Van Nostrand
What do you call a medical student who is last in his graduating class?????
22 Sunday, 16 January 2011 16:39
Concerned patient
CRNAs providing unsupervised anesthesia? If you want to save a few more bucks why not just have anesthesia techs administer the anesthesia? I'm sure the anesthesia tech organization would have no problem sponsoring a study supporting the equivalency between CRNAs and anesthesia techs. There is no free lunch. If you want the best, brightest, most educated person to administer your anesthetic then that will be an anesthesiologist. Being entitled to the best health care money can buy is the American way and I won't accept less. That is why I have a cardiologist managing my hypertension. Unfortunately the uneducated patients who don't insist on MDs administering their anesthetic are the ones paying the price.
21 Sunday, 16 January 2011 12:21
Eric C
"Keep in mind anesthesia is the only medical specialty that is not dedicated to the curing of disease"

If you define being a physician as someone who "cures diseases" there are very few physicians in this world. What Doctors due on a daily basis in all specialties is not curing disease it is managing pathology. So is it any different when an anesthesiologist manages intra-operative heart failure, dysrhythmia, COPD, asthma, pulmonary HTN, anaphylactic shock, sepsis, PE, hemorrhagic shock etc when compared to cardiologist, pulmonologist, ER physician, internal medicine doctor. I think many individuals feel that since anesthesiologist do not treat pathology of a particular disease process chronically that they do not treat or "cure" pathology which is an incredible underestimation of an anesthesiologist skill level. Not to mention there are a large number of fellowship trained anesthesiologist who are attending physicians in charge of running critical care units all over the united states, who are able to perform TEE to help with the diagnosis of intra-operative cardiac pathology, who treat the sickest babies all over the country and the list can go on and on. So to state that "anesthesia is the only medical specialty that is not dedicated to the curing of disease. Rather, it is the removal of pain, along with the optimization of each patient's unique disease status. Many CRNAs are fully capable of doing this, and doing it independently." is an extreme over simplification of the practice of anesthesia. Can a CRNA give an anesthetic without supervision to a 35 yo male with crohns disease requiring a small bowel resection with out any adverse outcomes I would say yes...can a CRNA do the same procedure on the same patient with severe pulmHTN without any adverse outcomes I would say no. So how can you give CRNAs independence to practice independently when the vast majority are unable to provide anesthesia to more complex patients without supervision. Are you saying that CRNAs should be independent of supervision and get to pick and choose what cases they are capable of doing while getting paid the same as an anesthesiologist with only a fraction of an anesthesiologist education and knowledge level? Explain to me how this is good for patient safety and how this is going to make healthcare more affordable?
20 Sunday, 16 January 2011 07:59
Jonathan Deutsch
As many anesthesiologists have commented on their immense worth, my comments will be brief.

In my time delivering anesthesia, I've seen many CRNAs and MDAs, some excellent, some horrible. Indeed, anesthetic knowledge and it's practice is within the scope of both - but how this knowledge is used is on a continuum. In isolation, yes - CRNAs and MDAs both possess the knowledge needed to practice independently. In reality, both providers can be used efficiently and collaboratively. Thus, the best model would be a collaborative one, not a supervisory model.

Unfortunately, for reasons not at all related to patient saftey, and closely related to preservation and greed, physicians have said they are needed in every anesthetic. This is an outright lie, and should be treated as such. Physician consultation is at times helpful, especially since their experience can be broader in comparison.

But all providers have their limits - even physicians - and this is exemplified in how often they consult one another. In the same way, CRNAs know when they need to consult a physician - be it an anesthesiologist, cardiologist, or surgeon. They are full professionals in their own right - and the practice model for anesthesia MUST be a collaborative one if it is to be mindful of the professionals involved, and financially stable.

But this model will never be endorsed by the ASA, because it admits that 1) Registered Nurses can be educated to act independently at the highest practice standards, and can even advance the science of anesthesia and 2) it puts CRNAs and MDAs on too close of a playing field. Simply, this removes too many potential dollars out of the pockets of those leading the ASA.

While some physicians are truly worth every dollar they are paid - others make their living 'supervising' from outside of the operating room. These physicians are often the loudest when it comes to how much they are needed.

Keep in mind anesthesia is the only medical specialty that is not dedicated to the curing of disease. Rather, it is the removal of pain, along with the optimization of each patient's unique disease status. Many CRNAs are fully capable of doing this, and doing it independently. Others benefit greatly from physician consultation.

In addition, not all anesthesiologists are equal. Some barely meet requirements, and enter their practice with minimal training in certain aspects of anesthesia. Many are never certified in anestheisa. Yet, we trust them because of their "MD," which may very well be from a sub-standard, non-American school.

For example - I've spoken to many new attendings that were deficient in regional anesthesia, while many CRNAs, especially military trained CRNAs, are not only excellent at regional anesthesia, but are leading the field in new techniques.

Physicians who comment here and disparage CRNAs are ruining their credibility. CRNAs have and will continue to provide excellent services to Americans, as they have been doing, with the same saftey rate of their physician counterparts, for over 100 years. Unfortunantly for the ASA, the time of society swallowing the ASAs propaganda coming to a close. Many new MDAs are fighting more fiercely than ever, but some new attendings are embracing the collaborative model.

Clinicians in collaborative practices know that greater productivity is found when all clinicians have autonomy and respect. They know that their national organizations would be better off spending their time focused on patients, rather than the need to defend themselves or the need to demonize others. They know that anesthesia is a unique field in American medicine, one that has been shared by many professionals, including dentists. And of course - they know that patients - because patients ARE the focus of our careers - patients will be better off when collaborative models become the standard in American anesthesia.
19 Saturday, 15 January 2011 22:57
Jim DelloRusso
Mr. Knowlton is gravely in error in his conclusion and his reasoning.
Advanced practice nurses, while helpful in many situations clinically, function best when they must defer/refer/collaborate with their affiliated physicians due to their general lack of knowledge and skill in caring for the more difficult and challenging situations, eg., hypertension or heart failure for primary care, higher risk pregnancy and cesarean section, and more difficult surgeries or patients for anesthesia care. They do not equate with physicians, and especially CRNAs do not equate with Anesthesiologists.
The study that Knowlton cites is a typical response and bureaucratic example, one that superficially seems to show nurse anesthesia care is as good as physician care, when the reality is that the data is NOT clinical, it is based on administrative billing data. Such data is inherently limited and NOT applicable for reaching clinical conclusions. It is not scientific to do so.
Here in California, we recently had Governator Shwartzenegger, a miserably failed politician, unilaterally decide to allow the state to opt out of the time-honored mandate that CRNAs be supervised by physicians (he did not consult with the State Medical Board, the state anesthesiology society, or allow public comment on this policy change, all of which are required by law). In my l letter to the Governator, I wrote the following, which is my opinion of CRNAs:
"I firmly believe that nurse anesthetists should NOT be allowed to practice independently under any circumstances.
I have practiced anesthesia for 22 years in a variety of circumstances, including academic settings and private practice. I have been an anesthesiology administrator for many years as well. I have had the opportunity to interact with, supervise, work with and teach Nurse Anesthetists (CRNA) and student nurse anesthetists, so I believe that I can speak with confidence and significant experience regarding training, standards of care and qualifications of CRNAs.
The training and education that CRNAs receive, while more extensive that regular Registered Nurses, is not even comparable to that which Anesthesiologists undertake. Two years of nursing education, one year of critical care nursing training and one year of anesthesia does not compare with four years of medical school and 4 years of internship and residency training, neither in length nor scope nor depth of education and experience.
I have worked with many CRNAs. Their skill level, training, experience, confidence and quality of care vary widely. Some CRNAs are excellent and compare favorably with their physician counterparts. However, the vast majority, in my experience, do not. This is not to say that do not fulfill a role in anesthesia delivery and in some operating rooms; however, in my opinion, it is most safely accomplished under the oversight and supervision of a physician, and preferably an anesthesiologist. Allowing any CRNA to practice independently, while only few can adequately do so, is frankly dangerous and a significant threat to patient safety.
I hope that our current unrelenting drive to 'improved' healthcare does not incorporate opinions such as those of Mr. Knowlton and other bureaucrats, most of whom are not truly seeking to improve patient safety, but are merely trying to minimize costs while pushing personal agendas.
18 Saturday, 15 January 2011 14:57
Eric Holley, M.D.
Just a point of information. Mr. Zwerling has A.L.O.T of initials after his name. Let's break them down.

CRNA - Has completed nurse anesthetist training. Good.

DNP - Doctor of Nursing Practice. Now Mr. Zwerling is Dr. Zwerling. A bit misleading?

DAAPM - Diplomate of the American Academy of Pain Management. Check out their website. This is NOT board certification. You pay the fee and take a test, but mostly you pay the fee. A search in my area included nurses, doctors, dentists, naturopaths, etc. You decide how useful this is.
17 Saturday, 15 January 2011 14:49
Virginia MD
Mr. Knowlton-

I appreciate your commentary and view it as only that. You probably should have mentioned that your name appears on the Board of Trustees of the New Jersey State Nurses Association. Not exactly an unbiased source are you? Also, I found it interesting that the New Jersey Health Care Quality Institute supports the Leapfrog Group's initiative to have ICU's staffed by critical care physicians. Are you aware that it is an anesthesiologist who heads up this Leapfrog committee? So patients in ICU's deserve a physician /anesthesiologist but not in the OR?? Seems a bit of a double standard. Anesthesia in America was introduced by Crawford Long and popularized by Morton (neither were nurses). Physicians became involved in anesthesia to improve its safety. Anesthesia has an amazing safety profile thanks to the hard work of anesthesiologists. Physicians are the ones writing the textbooks, conducting research and development, staffing committees, formulating guidelines and advancing the field. Where would we be without these anesthesiologists? Probably still dropping ether. You also alluded to a "study" in the journal of Health Affairs. This "research" is politically-charged and poorly designed. It was privately funded by the American Association of Nurse Anesthetists and involved a retrospective chart review of billing codes. This is hardly good evidence based medicine. Every other "study" has the same flaws, and is no more than political propaganda. You then went on a strange tangent about independent midwives. You are absolutely correct that they can practice independently and there is no "data" to suggest that women in New Jersey are better served by an OB/GYN. This is of course true until a patient needs an emergent operative delivery (i.e. C-section) when it's sure nice to have a MD nearby. I currently work with CRNA's and have the opportunity to train student nurses anesthetists (in addition to physician residents). I appreciate the skill set and knowledge of my CRNA colleagues. I do not totally disagree with your argument (i.e. independent CRNA practice), but I believe it is much more complex than a few simple paragraphs. If you want a real study then randomize new CRNA grads and physician anesthesiologist to all areas of anesthesia including high risk OB, emergency heart surgery, complex pediatrics and pain medicine and let's see how it goes. However, no physician (myself included), patient or CRNA in their right mind would allow this to happen. Like all things in life, the answer probably lies somewhere between the two extremes. Thank you for presenting one of those extremes.
16 Saturday, 15 January 2011 13:33
Roger W.
You can get your CRNA degree online. Nice. Proves my point. We are doomed.
15 Saturday, 15 January 2011 13:29
Roger W
Interesting that there is no mention of the millions the CRNA spends to lobby politicians and "peer review" journal to push there agenda. In most state capitals the nursing lobby is the most powerful and nurses are now one of the highest paid professionals in the country, making in most cases more than doctors on a per hour worked basis. Power lobby and good marketing. But not improved training. It is a sad day in America when more education is looked down upon and called unnecessary and short cuts and a lack of education is called "efficiency" . We are all doomed in the USA with this type of thinking.
14 Saturday, 15 January 2011 12:04
JK in GA
Wow, where should I start?

Mr. Knowlton would have you believe that the mere title of an article is sufficient to tell you "everything one needs to know". Incredible. That means I can just read the headlines in the newspaper and skip all that other stuff that takes up space - you know, things like facts, opinions, real data, etc. Apparently all that is unnecessary. All I need to do is create the headline or title and the content doesn't matter. Tell me, where and when do they teach this in school? Just think what would happen if we took the title of this article as gospel, instead of the pitiful piece of political pandering that it is.

Mr. Knowlton is a political bean counter at best, and a political hack at worst. Like any bean counter in any business, the mantra is "cheaper is better". That of course is absurd on it's face. One can try to make an argument that CRNA's with 6-7 years of post-high-school education are "equal" to physician anesthesiologists with twelve years of post high-school education, but that argument falls on it's face as well. The idea that CRNA's are a "superior choice" seems to suggest an opinion that is bought and paid for, much like the opinion in the Health Affairs article Mr. Knowlotn cites, that was indeed a study bought and paid for by the American Association of Nurse Anesthetists.

Mr. Knowlton also appears to have a problem interpreting data and making conclusions vased on that data. Although the malpractice rates for OB/GYN doctors is certainly significantely higher than an anesthesiologist, you can't make the the lowest rate of one and the highest rate of the other and claim the risk is "16 times" higher. He calls this objective, while his entire article is loaded with subjective puffery and opinions with no basis in fact.

The comparison to nurse midwives is misleading at best. CNMs do not have the full scope of practice that OB/GYN physcians do, so using them as an argument to broaden nurse anesthesia scope of practice is pointless.

And while we're discussing facts, or the lack thereof - Mr. Zwerling's opinion noted in the response above would have you believe that Mr. Knowlton's opinions somehow represent "science rather the PR rhetoric". Nothing could be further from the truth, and lets remember that Mr. Zwerling is hardly an unbiased respondent to this article.

Editorials by their very nature are full of opinions and short on facts. Mr. Knowlton's effort most assuredly fits that criteria.
13 Saturday, 15 January 2011 10:20
Angela Richman, APN/A
I am an APN/Anesthetist and have practice in many different settings in the past 35 years. I have worked as a solo anesthetist and in a team. This battle has been going on since APN's were granted the ability to "direct bill" for anesthesia services. There are indeed multilpe studies proving that we are safe providers of anesthesia, but the most important fact is that NO GROUP, organization or Department of the government has the right to restrict ones ability to practice! The Board of Nursing has specific regulations on how APNs must practice, our National organization defines our scope of practice and there are laws that mandate how an APN must practice in New Jersey.
Its time we stop fighting this turf war and concentrate on all our patients.
12 Saturday, 15 January 2011 03:03
California does not allow independent practice. Medicare opt out has to do with billing. Scope of practice in CA requires MD supervision. So please dont twist facts. Also give us the name of your successful crna practice and city so we could verify since you act so high and mighty. I am sure everyone loves you because youbare a yes man and dont advocate for patients. Administrators dream come true. Ever occur to you maybe you are the greedy sob?
11 Saturday, 15 January 2011 02:56
Anesthesia is not hard. I am in a good crna school. I will be ready for independent practice in 2 months. Cash money, baby!!!!!!
10 Saturday, 15 January 2011 02:50
Joan z
My 7 yr old lost his hand 10 yrs ago during appendix surgery because CRNa placed iv in artery instead of vein and put medicine that damaged his hand Case settled. Our lawyer said crnas have paid his 3 kids through college. Buyer be ware. There are good crnas. But we had horrible experience. I have 3 surgeries and always insist on doctor. Same with my surgeon. I dont want nurse operating on me.
9 Saturday, 15 January 2011 02:47
Elizabeth WT
am a practicing CRNA for 15+ years and think this debate has gone completely crazy. First of all, to the other CRNAs who are salivating at the prospect of running the show by themselves, be careful what you wish for. We do not take call like MDs, our hours are better, and if you actually look at the per hour salary, we are closer to anesthesiologists than you realize. Secondly, I can honestly say I would not be the competent CRNA that I am today were it not for the vigilant supervision and teaching that anesthesiologists have provided me over the years. So many times in my career, the you know what has hit the fan, and the anesthesiologist has come to the rescue and prevented me from looking like an idiot. Sure, I feel confident now and can do many ASA1 and ASA2 cases without much supervision. However, knowing that an anesthesiologist is around the corner to help is something I think is genuinely better for the patient. Let's be honest here. The anesthesiologists did go to medical school and residency, so obviously they are going to have more knowledge and skills than we have. That being said, I do not appreciate the belittling that some physician groups have done towards CRNAs --- we are an essential and valuable part of the anesthesia team and should be treated accordingly. The badgering that is going back and forth is ultimately all about money and should be about patients. Do I think we should be supervised? --- yes. Do I think we should be treated as useless technicians? --- no. We need to increase the dialogue and be respectful for our patients sake.

Elizabeth WT
8 Saturday, 15 January 2011 00:50
Mike Mack
As an independently practicing CRNA I can assure everyone here I am as competent as any anesthesiologist and I work entirely without them. Our group actually took the contract away from an ALL MD practice within a major city center. Since then the efficiency in the OR has increased by 40%, anesthesia complication decreased by 10% and the admin, surgeons, OR nurses and PACU nurses are happier than they have ever been (and say so all the time). The patients have nothing but good things to say (the satisfaction scores have increased with anesthesia) oh, and the hospital saved 4 million dollars a year in stipends to help pay for the MDs salaries.

I could masquerade as an OR RN and tell a bunch of defamatory stories about things Ive seen Anesthesiologist do as well but I am not as unprofessional as my detractors obviously are. Sufficed to say I challenge them all to prove ANYTHING they are saying here. The fact is their comments here only serve to evidence what Mr Knowlton has said about the REAL reasons ($$$$) they attack us so vehemently. He echos what recent California Supreme court Judge Busch said when the MDs attempted to sue the government to stop CRNAs from practicing independently in this comment

"In the final order, Judge Busch said that while the CSA and CMA seemed to suggest that the opt-out creates safety risks for patients, they “did not present any evidence on that point nor did they substantively rebut the evidence presented by [CANA] demonstrating that the opt-out does not present safety risks.” Evidence presented by CANA included two national anesthesia studies published in 2010 that confirmed the safety and cost-effectiveness of nurse anesthetists."

Obviously he saw through the smoke and mirrors as well.
7 Friday, 14 January 2011 21:39
Cindy G
Who trains CRNAs? A lot of the training is done by M.D. Who has written all the well known texts, "Millers Anestheisa" used by CRNA? An M.D. Who stands up to surgeons in dangerous situations?. In my old job the CRNAs were scared of surgeons and would call the M.D to talk to the surgeon. I was a circulating nurse and would cringe when a new CRNA would intubate, cutting the lips of patients. They woke up so much pain. Big difference. But people dont know. How about neonates and really sick patients? If I was only a malpractice lawyer I would make a million bucks going after the CRNA errors. Man you guys don't know.....

Cindy G.
6 Friday, 14 January 2011 21:22
How about what patients want? Its nice that the CRNA from PA wants to make more money and advocate for his profession. But we the public want to choose. I want to choose an M.D. The cost is the same. I called my insurance today and they said they pay same no matter who gives anesthesia. Also, if there are 25 million anesthetics given by CRNAs why do they need this regulation removed. They are already doing all the anestheisa in the US. Since there are 25 million surgeries, what more do they want. They are doing all the anesthesia. This apparently is a lie by the nurse lobby who fudges the numbers and doesn't tell you that a freshly minted CRNA is know as "007" in the business. i.e. They have the license to kill.
5 Friday, 14 January 2011 21:07
This is so wrong I don't know where to start. Barbers did surgery 125 years ago, should we let them do surgery now. Anesthesia is safe BECAUSE of anesthesiologists, and their supervision. Do you know what the training differences are. One is a doctor. The other is a nurse. Studies cannot accurately asses anesthesia because death is so rare.Why, because of ANESTHESIOLOGIST in the last 100 years working to make anesthesia safe.

Johs Salter.
4 Friday, 14 January 2011 20:38
Mindy W
Mr Knowlton,

How many hours have you spent in an OR? I am an OR nurse at an institution that uses both CRNA and Doctors to provide the anesthesia and I can tell you that there are some CRNA that I would allow do my operations if I was have a hernia repair or even bowel resection etc but at the same time these are the experienced CRNAs. I would never let a newly graduated CRNA touch me without doctor supervision even for the simplest procedure. But on the other hand I would have no problem letting a newly graduate anesthesiologist provide my anesthesia. Trust me when I say it is a good thing that CRNAs are supervised until the doctors have spent years continuing to teach the CRNAs after graduation.

Mindy W, RN
3 Friday, 14 January 2011 19:52
Thomas C. L.
I love how people without MDs or RNs who have probably never spent more than a day in an operating room (like Mr. Knowlton), seem to be the loudest and most one sided. As a patient who has unfortunately had to endure 7 surgeries, one of which I almost didn't survive, I know first hand the true value of physician anesthesiologists and the need for supervision. I had an open abdominal aortic aneurysm (AAA) last year and suffered significant intra-operative blood loss. Ultimately, I had a heart attack in the OR and was saved by a physician anesthesiologist. The nurse (CRNA) who was in the case did not give me the appropriate fluids in the OR while I was hemorrhaging, which lead to the problem. The rhetoric going on these days that suggests nurses who never went to medical school or anesthesiology residency are somehow as trained or knowledgeable as anesthesiologists with MDs is absolutely absurd and insulting to the fine physicians that saved my life. Also, I dissected my surgery and hospital bill when considering litigation and discovered that CRNAs are paid quite closely to anesthesiologists. This shocked me, considering all the rigors the physicians had to endure to get into medical school, finish medical school, and then endure an arduous anesthesiology residency for years.

It disgusts me that Mr. Knowlton who could only dream of having the intellectual capabilities of getting into medical school feels he can sit from his ivory tower as CEO and equate nurses with physicians. Please get an MD (or even an RN), and then pass judgement on an issue you are so clearly ignorant about.

To all other patients who may be reading, I can only tell you that having a physician looking over your care is worth every penny. It certainly saved my life

Thomas L
Patient Advocate
New Jersey
2 Friday, 14 January 2011 18:55
Art Zwerling
Mr. Knowlton,

Thank you for an honest, and well reasoned response to the Trojan Horse of "Patient Safety" that the ASA continues to attempt to sell to the public. You have eloquently and accurately placed the realities of anesthesia outcomes where they ought to be; founded in science rather than PR rhetoric.

The truly unfortunate issues are the tremendous loss of resources and professional discord this has generated. Our patients and economy would be much better served by paying attention to the science rather than the political rhetoric of any trade organization.

Thanks once again for having the integrity and courage to publically state your arguement in favor of autonomous/cooperative CRNA practice.

Best regards,

Art Zwerling, CRNA, DNP, DAAPM
Elkins Park, PA
1 Friday, 14 January 2011 18:47
Supervision is an obsolete cash cow.

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