Tuesday, December 8, 2015

Anesthesiologists and CRNAs: Not Separate, yet Equal.

Why Have Both?

        Like many career fields and practices, general anesthesia came about to solve a problem. This  universal problem that becomes an extreme issue when someone cuts into your bones. Pain is this problem, and anesthesia is the solution. Anesthesia, in its many forms, has been around almost as long as recorded history tells us, with nurses administering the anesthesia under surgeons’ supervision. In my experience talking with doctors and nurses, I have gotten an overall feeling that the game is changing a little bit in the medical field. Doctors are liable for so much that all they do is paperwork now. There is so much technology that can tell us more than we thought imaginable just a few years ago. This allows physicians to be very specialized. Talking to a nurse anesthetist was the reason why I want to become one. I usually tell people what he told me when people ask what a Certified Registered Nurse Anesthetist (CRNA) is. That is, a CRNA is basically an anesthesiologist that didn't have to go to medical school. As a generalization, the anesthesiologist has more liability and tells the CRNA what to do. 

         CRNAs are certified to do nearly all of what anesthesiologist can, yet they need to be supervised in many instances. Multiple problems could be solved with the progressively complicated system if CRNAs could work independently. Although some may say that anesthesiologists’ specialties are crucial to the medical field, Nurse Anesthetists should replace anesthesiologists because student debts from medical school would drop drastically, it would give CRNAs opportunities to utilize all of their training, thus reducing the redundancy of having two such similar specialties in the same workplace. It would also eliminate a level of potential miscommunication between physicians working together to improve and save lives.

History of General Anesthesia

  • 4000 BC -The Babylonian people used opium as anesthetic. This remained a popular method for thousands of years, and also started the trend of finding plants to relieve pain. Among these were mandrake, henbane, hemlock, wine, coca leaves, and vegetable ash.
  • 1600s - Ether became popular, and other methods paved the way for more modern techniques such as intravenous therapy. As time went on, doctors and pharmacists refined these practices, finding a more specific gas, nitrous oxide, and isolating the substance morphine from opium.
  • 1800s - These decades were full of experimentation and exploration. Cocaine, nitrous oxide mixed with oxygen, intravenous and spinal anesthetic all were popularized in these years. Most of these practices were first tested on animals, then the doctors would test it on themselves. In the case of chloroform, it was originally used for pain in childbirth, controlled by drip bottles.
  • 20th Century - The first half of the century brought about improvements in medical tools and control of substances. The second half was when numerous gases and intravenous anesthetic were discovered, a lot of which are still used today. (Wood)

  As this history shows, there have always been advances in the field that people will have to learn about and new procedures that come with these discoveries. At points like this, everyone becomes beginner again in their associated roles. Scientists continue to discover new methods which affect the way anesthesia is administered. Only recently have specialized anesthesiologists been implemented in supervising the work of Certified Registered Nurse Anesthetists, or CRNAs. 

        “Nationally, nurse anesthetists have been administering anesthesia to patients for 150 years, long before it was a physician specialty. Traditional training took place in hospital-based or military programs that ranged in length from a few months to a few years. Surgeons were, and remain to be, strong supporters of CRNA practice abilities and rights.” (Molina) I believe that this is the what the profession should aim for once again, and the benefits are very impactful. 


 Economic Benefits

        Student loan debt in America has grown to over 1.2 trillion dollars. (Gordon) On average, this comes out to over $35,000 per person. Medical school is especially brutal when it comes to student debt. Numbers from the Bureau of Labor Statistics help us calculate not only medical school debt, but the opportunity cost on top of the debt and time spent during medical school. The average medical school student finishes with an average of $170,000. If you take into account the opportunity cost of schooling instead of working with a bachelor’s degree for the 4 years of medical school, plus another 3-7 of residency, a student is missing out on over 20,000 hours of work at an average of $30/hour if not in medical school. This comes out to close to $800,000 total cost. (Bureau)

        In contrast, the path for CRNAs can be a lot shorter and include a lot less debt. Nursing programs can be done in as little as a year, and after a year or two of practice, nurses can apply to CRNA school which can take as little as 18 months. Although that is the ideal, it illustrates the stark difference between the two professions. If the transition was made to provide CRNAs to assume the responsibility of anesthesiologists, the medical school debt in the country would be positively effected, while simultaneously stimulating the economy with an influx of working CRNAs instead of in-debt medical school students. Some may argue that the extra schooling provides anesthesiologists with specialized knowledge crucial to the field. But even if CRNAs were required to take a couple more years specialized training, there would still be a difference of thousands of dollars and hours. In my opinion, this change would suddenly make the profession much more accessible and appealing to a larger working population.

Medical Workplace Benefits

          Related to the schooling of CRNAs and Anesthesiologists is the scope of practice in each profession. “Challenges related to other disciplines’ recognition of the CRNA scope of practice create barriers to practice. Many state statutes prevent CRNAs from practicing to the full extent of their education and training.” (Malina) Because of the current system, CRNAs are limited in their abilities because in many instances, they need to be supervised by an anesthesiologist. The redundancy and financial effect on the hospital are obvious when the general safety standards, quality of care, and practice is usually the same between the two professions. To a lot of people it seems like there are two of the same person doing the same job. Reworking the system would give CRNAs opportunity to practice more fully what they have been specialized to do. 

         According to Dr. Randall Maar, MD, of Children's Hospital Colorado in Aurora and a member of the ASA Board of Directors, a common argument in the debate is that removing the CRNA supervision requirement will enable more nurses to practice in rural hospitals, thus increasing medical care in underserved areas where anesthesiologists are scarce. Proponents of the CRNA opt-out argue that it will allow hospitals to cut costs associated with recruiting anesthesiologists and draw from a larger pool of available CRNAs, particularly as hospitals expand or add additional services in different locations. "It gives the hospital or contracted anesthesia group an alternative to provide anesthesia service in a more cost-effective way, and it gives more flexibility," says Dr. Thomas Wherry, MD, of Surgery Center of Maryland. (Tawoda)

Patient Care and Safety Benefits

         Communication is key for success in any sort of medical field. There needs to be clear, direct communication between nurses, and to patients, parents, doctors, residents, interns, and whoever is involved with the patient. The purpose is to make sure that everyone is on the same page and has the information they need. Time is usually a precious resource so the extent of this communication needs to be efficient. In the medical field, written communication is required almost all the time to document patient information, vitals, and procedures. Verbal storytelling, however, is crucial to ensure that the most important information is not overlooked. Without this clear correspondence, there can be dangerous, and often times fatal mistakes. 

         For example, information is received from the patient and needs to go to the nurse, then the nurse anesthetist, then the anesthesiologist, before the surgeon, and most of the time information will be sent back down the line for each worker to perform their duties. There need to be enough players in the game to get the job done, but too many can bring more problems than good. Eliminating the need for anesthesiologist supervision will improve the communication in the workplace. Like a fireman’s line, as the bucket is passed from person to person, there are more chances for the water to be lost. Likewise, the information passed to and from physicians has the potential to lose important details regarding the patient. 

         A study from UC San Francisco and eight other institutions found that improving communication between health providers can reduce patient injuries from medical errors by 30 percent. In 2013, between 210,000 and 440,000 patients suffered some preventable harm from hospital mistakes. (Noguchi) Words are powerful, especially when what is said determines the care of a person. Reducing the repeated relay of information can reduce the potential for miscommunication. When lives are on the line, physicians need to focus on the task at hand and be able to work in harmony with their teams.

         In conclusion, the economy, the medical field and patients all around the country would be better off if CRNAs would be given responsibility in place of anesthesiologists. The time and money spent on medical school is unnecessary when CRNAs are doing (or can do) nearly all that anesthesiologist can. The numbers of accidental deaths due to hospital mistakes would decrease if we remove a level for potential miscommunication. As the examples show, the benefits that would result are significant and far reaching. The simpler path and minimal debt brings with it positive outcomes like a larger hiring pool, more access to areas with little or no anesthesiologists, and the ability to draw more people into the profession.


Bureau of Labor Statistics, “Economic News Release” Table 5. 3rd Quarter 2015 Averages. Last Modified Date: November 10, 2015.          http://www.consumerfinance.gov/blog/category/student-loans/  

Gordon, Ashley, “Student Loans”, Oct 20, 2015. Consumer Financial Protection Bureau. http://www.consumerfinance.gov/blog/category/student-loans/ Accessed Dec 4, 2015

Malina, D., Izlar, J., (May 31, 2014) "Education and Practice Barriers for CRNAs” by Debra Malina" OJIN: The Online Journal of Issues in Nursing Vol. 19, No. 2, Manuscript 3.

Noguchi, Irene, “Miscommunication: A Major Cause of Medical Error, Study Shows”, State of Health, KQED News. November 25, 2014

Tawoda, Taryn. “Issues is the CRNA Supervision Debate: Anesthesiologists Weigh In”. Becker’s ASC Review. May 31, 2012

Wood Library-Museum of Anesthesiology, “The History of Anesthesia”.

 http://www.woodlibrarymuseum.org/history-of-anesthesia/ . Accessed November 13, 2015

Image by: Julia Fullerton-Batten, http://www.menshealth.com/health/junkie-or, anesthesiologist.jpg. Twice.

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