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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.