Dr. Jay H. Epstein: Anesthesia needs to be given under doctor supervision

The commentary below from Dr. Jay H. Epstein is in response to Peter Schorsch’s Jan. 8 post on SaintPetersBlog.com urging legislators to give nurse anesthetists the authority to administer anesthesia without the supervision of a doctor.

When it comes to anesthesia, lives should not be put in jeopardy.

Thank you for this opportunity to address several points raised in your recent blog in which you advocate allowing nurses to do the work of physicians when it comes to the administration of anesthesia.

First, you inaccurately state that “national studies have shown time and time again” that nurse anesthetists deliver the same quality of care as a physician.

There are no such studies.

While this statement is demonstrably false, it is presumably based on a misreading of a single study (the data used in it is eight years old) that was paid for by the national nurse anesthetist lobbyist group (the AANA.)

But even taking their data (and not the editorialized title) at face value, please note that the actual data in the study clearly shows two things that directly and immediately counter your premise.

First, the study states that the physicians were generally involved in more complicated surgeries than the nurses, yet their mortality rates were not significantly different.  If physicians were dealing with sicker patients and more complicated surgeries and the outcomes were no different, then the logical conclusion is that physicians provided a higher standard of safe care.   There should have been a mortality difference, but there was not.

Second, the study shows that in the states that have allowed nurses to act without a doctor’s supervision, mortality rates not only increased over time (from 1.76 to 2.03 per 100 patients) but in the final year of the study (2005) the mortality rate in so-called “opt-out” states was more than 50 percent higher than in states that required doctor supervision.  50 percent higher!

To sum up, the only “recent” study (with data that is nearly a decade old) that is on point actually shows — with extreme clarity — that doctor-led anesthesia care is safer than when nurses act without the supervision of a trained physician.  There are no other recent studies.

Considering the differences in education, training, and experience between anesthesiologist physicians and nurse anesthetists, these results are hardly surprising.

Physician anesthesiologists have twice the schooling and more than seven times the clinical training of anesthetists, and the nature of that training is very different.

Nurses are trained to be medical technicians (and to be clear, they are a vital and valued part of the anesthesia care team) while anesthesiology physicians are medical doctors who are trained to understand underlying medical comorbidities, formulate medical diagnoses, and recognize the intersection between surgery, medicine, and pharmacology.  The appreciation of these complex interactions is crucial.

The administration of anesthesia is much more dangerous than it appears and involves far more than simply slipping on a mask or injecting someone with medicine.  A patient’s outcome depends upon a detailed review of their medical history, the careful selection of a properly designed anesthetic plan, contingency plans for complications, and diagnostic skills to assess and treat postoperative problems.

In short, there is a reason we have twice the education and more than seven times the clinical hours.

The expansion of healthcare access must take into account safety, outcomes, cost, need, and — quite simply — proven results.  There is not projected to be a shortage of anesthesia physicians or anesthetists, as we heard in testimony earlier this month.  There is, however, according to the nursing industry, a chronic shortage of nurses that is projected to be the worst shortage in more than 50 years.

The physician-led anesthesia care team model works very well and there is no urgent need to look for alternative delivery systems.  When they are facing a procedure, Floridians deserve to have the best-trained clinician available and directing their care.   That person is a physician anesthesiologist.

Guest Author


20 comments

  • Connor Chase

    February 4, 2014 at 9:23 pm

    Dr. Jay’s argument was a slam dunk. How do we believe someone who pays for their own study and then calls is legitimate? I’m all for saving healthcare dollars, but not with my life on the line.

    • James L Johnson, MD

      February 5, 2014 at 9:59 am

      Your implication that CRNA’s are merely technicians is insulting enough, but the despicably sexist implication that CRNA’s should go back to being nurses (because of the shortage) and leave the anesthesia to “the real men” is over the top. I suspect that, if the CRNA’s under your supervision read this article, they should make your life a living hell, calling you for every decision and insisting on your continuous presense in the OR. To borrow a phrase we used back on the farm, “Buddy, I think you stepped in it!”

      • ca431

        February 5, 2014 at 8:01 pm

        Thanks, Dr. Johnson, for your acknowledgement of the value of CRNAs. I’m sure you and your CRNA colleagues work very well together.

    • ca431

      February 5, 2014 at 7:57 pm

      Are you implying that the ASA didn’t fund any of these safety studies either?? LOL

    • David

      February 23, 2014 at 10:56 pm

      Congratulations. You have just just become one of the unwary souls who believe in just about anything thrown your way. A slam dunk?!!! This argument is more of a smoke and mirrors approach and is nothing more than a blatant attempt to cloud the issue concerning anesthesia practice. If CRNA training was nothing more than medical technician training, then why do I have to endure a physician anesthesia provider who insists on giving my induction drugs, insists that I cannot perform central line access and most of the other “technical” aspects of anesthesia? I am considered a “god” after 5PM and am wondering why that is not possible during the day?

      Ultimately, the only issue here is one of money and turf. I am not advocating that CRNA’s are better educated. That has been the “mantra” of the physician providers responding, and the lone AA, who I do not fear in any way because he does not bring to the table what I bring to the table in the arena of anesthesia.

      I have practiced many many years. I have worked in one of the largest teaching hospitals in the country. Anesthesia has always been about doing the best job possible for the patient laying in front of you. Why we have lowered ourselves into a turf war befuddles me. THere is plenty of opportunity for everyone. My fear is that because of a few zealots in each group, we are risking the very patient we are trying to take care of. It is time we all sat back, took a deep breath, and laid out just what it is that is important and lay aside our biases. Time is much too short to be arguing over petty turf wars.

  • Leo Rodriguez MD

    February 5, 2014 at 9:35 pm

    Very well written Jay.

    I enjoy working as a Team with Nurse Anesthetists. We as Physician Anesthesiologists (not MDAs as some misstate), we are Perioperative Medicine Consultants, who can obtain consults, additional workup when appropriate and analyze the information to decrease cost while maintaining quality. Provide Perioperative Pain services and Perioperative Critical Care.

    Some CRNAs have chosen to misrepresent or misunderstand their education. The Intensity and Depth of Studies in Nursing School and Medical School are different, so the difference is not only in length but also in quality.

    Before a SRNA goes to Anesthesia School, they complete a year of ICU Nursing. Meaning they stay at the bedside with the patient to monitor the patient, administer the Medications and care for the patient as ordered by the Intern, Resident, Attending Intensivist and alert the Physicians should changes happen. They are not doing the thinking, nor writing therapy, nor inserting catheters. So according to some of the comments written by others we should get rid of the Intensivists, or the ICU RNs should be paid the same as an Intensivist. During the Anesthesia school they complete 1 year in the classroom and 1 year and 2 months of supervised patient care.

    Physicians are trained to do Critical Decision Making and give orders to an RN (an ICU physician does not stay at the bedside while the patient is in the ICU, they leave their care to the ICU RNs while they monitor the results of the Prescribed Therapy).

    Pain Medicine is not about taking a Course to place a needle in the back; Pain Medicine is a Medical Sub-Specialty in which the Mechanisms of pain are studied and different approaches including Injections, Psychology, PO Medications, Physical and Occupational Therapies are combined to improve the patient’s pain, while the Board Certified Pain Physician coordinates the Care.

    If we were to pretend that we are all equal, do we really need Engineers (we have contractors), do we really need officers in the battlefield if we have Sergeants? Each one of us is an important component of a Team taking care of patients, should you choose to be a different part of the Team, then there’s additional school required (Medical School 4 years, Residency 4 years and Fellowship if you choose to).

    We can’t think that Anesthesiology is injecting propofol, rocuronium, intubate the patient and if pressure goes down give ephedrine… That is the simple part, it is the Differential Diagnoses, the additional training and practice.

    Anyone is welcomed to acquire our level of Education, it requires MCAT, Medical School, USMLE, Residency. The President of the ASA, Dr Jane Fitch is a former CRNA that went to Medical School and Anesthesiology Residency and has a stellar carrier as a Cardiac Anesthesiologist and Chair of Anesthesiology in Oklahoma. We welcome all CRNAs to follow her path, we all better ourselves.

    CRNA school is not a Fast Track Medical School and Residency, if you think it is, you are extremely confused and misinformed.

    The Professors that teach in Medical Schools and Residencies are the ones who publish all the Science that we all read in books, the ones with NIH grants that have developed Pulse Oxymetry, End Tidal CO2, Transesophageal Echo…

    • David

      February 22, 2014 at 6:54 pm

      Dr. Rodriguez, I applaud your efforts in response to several of the postings, including that of “Dr. Jay”. However, before you go around dislocating your shoulders patting yourself on the back, you should get some of the facts straight!

      While I am not a perioperative medicine consultant, I can order consults during my pre-operative evaluation. And, before you get your hackles up, be advised that a great many CRNA’s actually do a lot of the preoperative evaluations in their practices and only on the day of surgery do some anesthesiologists get involved. If I think a consult is advisable, I call my attenting anesthesiologist, who is probabaly at home and tell them what I have done and the reasons for doing so. The length of my training has no bearing on whether or not I am competent enough to ask for a consult, as your missive would suggest. And, that is not a misrepresentation of my skillset or training.

      No where have I read in any comments that intensivists should be eliminated or that ICU nurses should be paid the same as they are getting paid. I make critical decisions on the spot in the operating room and have always had the backing of the anesthesiologist I am working with. I have done cases of the most complex variety alone without any supervision of an anesthesiologist. I am retired from the military so have worked alone. I have worked in a collaborative practice where everyone, CRNA and anesthesiologist was in a room. There was usually a resource person, usually an anesthesiologist around to offer assistance if I called them and asked for the assistance. I did not need to have one of them “lording” over me telling me what to do. I have also worked in a medically directed environment. After all, if you believe “Dr. Jay”, you would think that all we as CRNA’s are are medical technicians, period. If that is the case, then I should be placing all of the lines, doing all of the inductions and such without one of them feeling that they have to be in the room doing “technical” stuff, placing all of the blocks etc.

      You are correct that pain medicine is not just taking a course and be handed a needle! Yet, there are a lot of folks out there, CRNA’s and anesthesiologists who think that taking a course such as this grants them the title of “expert”.

      In the battlefield, there are a lot of “sergeants” who actually do to the order of battle while the officers are safely ensconced in a bunker somewhere. This is not always the case, but it is the case in some instances. So, your comparison is not valid.

      You are correct that pushing the plunger, paralyzing and intubating and turning the vaporizer 3 clicks to the right is not the essence of anesthesia. It is thinking and anticipating what is happening and reacting and doing the necessary actions that is the essence of anesthesia. To think that only an anesthesiologist has those skillsets is the product of warped, conceited, and small mind.

      Using Dr. Fitch as a “shining” example of what could be is also a bit of a stretch. She did what she wanted to do. The fact that she decided to become a physician anesthesia provider was her choice. Holding her up as an example of the right way to do things is also a reach on your part.

      I have not read anywhere in these comments that any CRNA thinks that CRNA training is a fast track to medical school or residency. Only physician responders seem to think that. Does this mean you are a bit frightened by the CRNA’s? I don’t know.

      Not all of the professors who do a lot of publishing and research are everyday anesthesia providers. They are far from it. The interpret the data collected by CRNA’s and residents who do the actual day to day work.

      The advances in anesthesia have not only come from the efforts of anesthesiologists alone as you suggest in your last line. They have come from joint efforts by everyone associated with the practice of anesthesia.

  • JW1081

    February 6, 2014 at 1:45 pm

    I have to agree with Dr. Epstein. Average American’s would overwhelmingly agree that physician led anesthesia teams are the safest way to go. The notion that CRNA only anesthesia is just as safe as the team approach is like comparing apple to oranges. CRNA only anesthetics take place at plastic surgeon’s offices, endo suits, surgery centers, and rural hospitals. The offices and centers/suits will only take care of the healthiest patients or the cream of the crop. Any major comorbidities and they are canceled and scheduled for a larger facility. For example, if a patients BMI is greater then 30 they have to be done at a hospital. Sicker patients from rural hospitals are commonly transferred to bigger hospitals where physician led anesthesia is the practice. The sicker the patient the more complex the case and the greater risk to the patient. Why not have more hands available? Aren’t two heads better then one? I think most people would agree.

  • tim miller AA-C

    February 6, 2014 at 5:29 pm

    As a vet (USMC 3rd Recon BN & 2/2) I want to thank the CRNA’s who have responded. I appreciate your service as do your brothers in arms. I salute you.
    I originally earned an AS in respiratory therapy then a BS in the same discipline. While I earned my BS in RT my 5 buddies earned BSN’s then went to CRNA School. Over the years I worked 7p-7a for almost eleven years as a RRT in the trauma ICU of a level 1 trauma center. I have met many extremely gifted and talented critical care nurses. As everyone knows, although a BSN is a 4year degree, only the last 2 years is spent learning nursing skills. The first two years of nursing school is spent in “core “courses such as English, MATH ect. Some of my very best friends of 20 years are CRNA’s and they are incredible people, AMAZING clinicians and I would let them put my own child to sleep….under the direct supervision of an anesthesiologist as part of a anesthesia care team (ACT). No matter how great these people are or how close I am to them, at the end of the day, from a professional standpoint (not personal), they are NURSES, trained in anesthesia. I currently work with CRNAs and I respect each and every one of them and I am proud to call them colleagues. Let me also say I respect the training CRNA’s must complete to earn their degree, I have trained with both SRNA’s and anesthesia residents and anesthesia fellows but to be very very clear, the training is not the same as that of a medical doctor trained in anesthesia.
    I am sincerely appreciative to the anesthesiologist, AA-C’s and CRNA’s that that took the time to educate and train me. I am also appreciative to the anesthesiologists who supervise me and my AA and CRNA brothers and sisters. I firmly believe in the Anesthesia Care Team model and believe it is the best model to provide the safest care for “OUR” patients.
    Sincerely,
    Timothy Miller AA-C , Fort Lauderdale Florida

  • German Echeverry

    February 6, 2014 at 5:31 pm

    Thank you for providing a clear response to all the misinformation eagerly published in the lay media by the CRNA lobby and it’s advocates. Exploiting the fact that most americans don’t understand what anesthesia entails, they have aggressively pursued an agenda of splintering off from the anesthesia team in order to advocate for higher compensation and benefits from employers. As you correctly pointed out, “the” study famously quoted by every CRNA with regards to this issue was contracted and paid for by their own lobbyist organization and might as well have been written by lobbyists themselves. At one point the CDC looked into conducting a similar study but eventually scrapped the idea because they realized a. the sample size required would be too large to do a statistically robust study and b. it would be unethical to put patients in harm’s way by denying them access to an expert if needed. Furthermore, aside from being outdated, their data was generated from billing documents, not clinical charts – missing many possible complications from anesthesia including death, heart attacks, arrhythmias, severe hemodynamic instability intraoperatively, incorrect medical management intraoperatively even if it did not lead to patient mortality, pneumonia, stroke, kidney failure, thrombosis and thromboembolism, severe post operative pain, prolonged or unanticipated mechanical ventilation, unanticipated ICU admissions, etc. in the peri-operative period (not just during surgery). It has been extensively criticized by statisticians, given that it was underpowered to demonstrate significance in outcomes reported (reason a. why CDC gave up on their study). Aside from the 50% mortality increase in opt out areas, there was a troubling 50 % overall trend in mortality (1 vs 1.5) which was NS due to lack of power (again, due to poor study design). In other words, the study was statistically sloppy and heavily editorialized to strengthen their agenda. Anesthesia is safer thanks to the culture of safety and development of optimal agents in our profession over the past 50 years. However, anesthesia is not safe, as any of us who works in the field knows. Every day is a battle, and it’s the patient’s life that is at stake. Though it is rare for a healthy patient having a routine procedure to die in the operating room, the same is not true for the very sick or the extremes of age. Beyond death, other problems can and do frequently occur as outlined above. Additionally, every medical problem a patient brings has to be considered and managed in the perioperative period by a physician, just as your cardiologist, pulmonologist, or nephrologist would. Most of the drugs we give in anesthesia can kill a healthy person if not properly administered. Furthermore, with surgical advances we are operating in sicker, older patients with more aggressive surgeries that can lead to dysfunction or failure of virtually all the organs in the body. Every medical problem a patient has can quickly decompensate leading to even more harm not just during the anesthetic itself, but even in the days following when patients are most vulnerable. I simply cannot understand the argument for allowing CRNAs to work outside of the anesthesia team. Why are we risking patient’s health, and lives? We all have our roles to play to ensure our patients receive the highest quality of care possible and ensure their safety at a very dangerous time of their lives. We shouldn’t be deconstructing the infrastructure of safety by suddenly assuming roles outside the scope of our training through legislative activism. As mentioned above, any CRNA who wishes to learn how to manage medical problems can do so my attending medical school and completing residency and fellowship if desired, in the process satisfactorily completing all the quality assurance measures inherent in the system such as MCAT, rigorous screening process to gain acceptance into medical school, demanding medical school work to ensure an individual possesses intellectual and psychological skills necessary to take on this level of responsibility and master the large body of knowledge, USMLE 1, 2, 3, and board certification, and rigorous 80 hour/week work schedules for 4-5 years during post medical school training to become a board certified anesthesiologist. As much as they want you to think otherwise, nursing school is not medical school “light”. The quantity and quality of training are entirely different leading to massive differences in depth of understanding. Nurse anesthetist training is a technical one that bypasses all but the most basic of medical knowledge of both basic chemistry, biochemistry and physics, as well as clinical science. No diagnosis or management of any medical condition is ever carried out. Be aware of who is taking care of you or your loved one. I have overheard CRNAs introduce themselves as “anesthesiologists” or as doctors (for having completing non medical doctorate degrees, and now CRNA schools are transitioning to awarding ‘doctorate’ degrees in order to advance their agenda). CRNAs can be a fantastic addition to the care team, but make sure they are working as a member of a team led by a physician anesthesiologist. We shouldn’t let the ambition of a lobby organization to undo all the gains we have made in the field with regards to patient safety and put the lives of ourselves and our loved ones in danger.

    • David Andrews

      February 6, 2014 at 11:42 pm

      No Harm Found When Nurse Anesthetists
      Work Without Supervision by Physicians

      Health Affairs, Brian Dulisse and Jerry Cromwell,
      2010(29):1469-1475.

      Pro tip- denigrating others does not elevate yourself.

      • JLK

        February 7, 2014 at 3:09 pm

        article above: – billing data from medicaid, paid for by CRNA lobby

        “Acknowledgments

        This research was funded by the American Association of Nurse Anesthetists. The authors are wholly responsible for the data, analyses, and conclusions.”

        • JW1081

          February 7, 2014 at 8:38 pm

          ha

  • [email protected]

    February 7, 2014 at 3:57 pm

    1) Why would a CRNA want to work independently and take the entire liability.

    First, the case law is clear in this matter. The CRNA working with an MDA is not insulated from liability anymore than if they work independently. There have been multiple cases where CRNAs IN care teams were found solely liable for a negative outcome AND cases where MDAs have been found solely liable when their actions during “a break” caused the negative outcome. CRNAs in ACT practices are not sued anymore or less than CRNAs in independent practice BUT CRNAs as a group are sued less than MDAs. The current research suggests that the reason MDAs are sued at a higher rate has to do with their initial dismissive interactions with patients. The most common cause of lawsuit is patient perception of provider not caring. Thats per closed claims.

    2) Is the cost to society the same for CRNA vs MDA?

    I agree with your statement on value but I think we disagree what that means. Since all available evidence shows no difference in quality of care and outcomes between CRNA only and MDA or ACT practice the value isnt in the initials. So it rests in 2 things.

    a) The cost to train an MDA is estimated by the AMA to be 1.01 million dollars per resident. This is government subsidized money coming from each of our pockets and ranging from GME monies (160K per yer of residency) to grants to medical schools. The cost to society for a CRNA is.. well zero. We actually pay for our entire education ourselves. In addition to this significant value is the fact that for every 1 MDA produced 2.5 CRNAs can be produced. Seems like pretty good value to me.

    b) Stipend costs. For every OR that MDAs are involved in within an ACT practice the MGMA estimated stipend cost to the hospital is ~ 140-160K. Stipends are considered the “low hanging fruit:” of healthcare economics and will be minimized or go away. A moderate size ACT anesthesia group costs the hospital a stipend in excess of 1.5-2 million per year. That makes anesthesia a cost center to the hospital, a BIG one. The cost DRAMATICALLY increases in an all MDA practice with a national average payor mix of 60:40 (cms:insurance) as you can imagine. CRNAs conversely, either are cost neutral or require minimal stipend to maintain 24/7 OB or call coverage. This is because the salary expectations are TOTALLY different and the fee for service CRNA (like myself), is happy doing a more work than the average MDA for less money. Good value.

    c) We dont actually make the same money for the same job. While CMS, Tricare and IHS pay us the same per unit (the lowest paying providers in existence) all other private insurers negotiate individual contracts with individual providers or groups. These contracts range dramatically in how they pay CRNA vs MDA only care even tho the EXACT same service is provided. Some insurance companies do not even pay CRNAs many pay at a lower rate per RVU. So it isnt the same at the end of the day in pay either.

  • Brence Sell

    February 9, 2014 at 9:58 am

    CRNA’s provide a valuable service as part of the anesthesia care team. That said, they do not provide the same services nor the same level of care as a physician anesthesiologist. The very notion is ludicrous.
    The vast majority of anesthetics in the US are given under the supervision of an anesthesiologist. The study published in Health Affairs cited above is fatally flawed, in that the determination of which cases were done without physician supervision was determined retrospectively from billing data. In fact, most of those cases were done under the supervision of a physician anesthesiologist.
    Anesthesia today is much safer than it was 50 years ago (when many more CRNA’s did work independently). The improved protocols, monitoring standards, and advancements have occurred due to the efforts of physician anesthesiologists, NOT CRNA’s.
    We should be reluctant to relinquish these improvements.

    • Robin

      March 17, 2014 at 9:44 am

      Well, I wouldn’t exactly say Ludacris. I have worked with some MDA’s and knew that it was a good thing I was there to make things right. A few examples: a doctor wanted to give blood without checking labs and I checked labs and the H/H was 12 and 38. Then, I took over for a Dr. who had the eyes taped open. Then, I took over a case with a patient on Coumadin with a high INR which was ignored…oh, and no type and screen. Well, he bled. I scrambled with the blood draws and sample tubes and the idiot just left. So, we have to judge by personalities and not by the letters at the end of the name. All in all, two people checking things is far better than one.

  • Bipen Patel, M.D.

    March 8, 2014 at 1:13 pm

    To be just and fair,I think that CRNAs are far better than Anesthesiologists. They are obedient and efficient. They are not arrogant and stubborn as the physician anesthesiologists. I am a vitreo-retinal ophtalmologist and I have employed a number of CRNAs and they are wonderful.

  • John Webb, M.D.

    March 10, 2014 at 8:03 am

    You don’t need to be a rocket scientist to push some anesthesia drugs and place a tube down the throat of a patient. I think that CRNAs are just fine. I am a plastic surgeon and I think that CRNAs are superb. I agree with Dr. Patel.

    • Robin

      March 17, 2014 at 9:37 am

      Well, there’s a little more to it than just pushing drugs and dropping a tube in someone’s throat. Suffice it to say that it does look easy to you because most of the patients in the plastic surgery arena are generally of better health and the surgeries are not too invasive. Some of the very, very sick patients need a little more attention. So, I liked your comment in defense of CRNA’s however, it makes it sound like our jobs are easy and Doctors are really giving us a hard time about an easy job that is lucrative. All in all, it’s not an easy job and with the sicker patients, the team approach IS the best way. 28 years exp. has taught me that. All in all, if it helps one patient, it is the way to go. After all, everyone wants to live.

  • Robin

    March 10, 2014 at 10:16 am

    Dear Jay,
    I am a well experienced CRNA with nearly 30 years experience. I wanted to tell you that over the last 28 years in practice the team approach has worked both ways. I personally have relied on Anesthesiologists in a crisis. And, they have relied on me. I work with good doctors, With the exception of the bad ones. Then, they have relied on me… I would give examples, but, do not want to scare the public. Suffice it to say that some of the newer and egotistical MD’s (or DO’s) I have personally saved from disaster. So, the upshot here is YES team approach works well…in both directions. Please email me. If you would like to discuss specifics.

Comments are closed.


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