Tuesday, September 7, 2010

Anachronistic Specialties?

The NY Times has jumped all over a couple of recent scientific articles asserting that certified registered nurse anesthetists (CRNA's) provide equivalent care as MD anesthesiologists. Already, it is legal in 15 states for CRNA's to dispense anesthesia without the overarching supervision of a physician. Furthermore, a study from the Lewin Group in California has demonstrated that CRNA-only models of anesthesia provision are far more cost effective that our current dual profession paradigm.
In the long run, there also could be savings to the health care system if nurses delivered more of the care. It costs more than six times as much to train an anesthesiologist as a nurse anesthetist, and anesthesiologists earn twice as much a year, on average, as the nurses do ($150,000 for nurse anesthetists and $337,000 for anesthesiologists, according to a Rand Corporation analysis). Those costs are absorbed by various institutions and public programs within the health care system.

This is a fascinating debate. And I expect MD anesthesiologists to fight for their interests tooth and nail.

To some extent, MD anesthesiologists have become a victim of their own excellence. Deaths during the administration of anesthesia occur at a paltry rate of 1/250,00 cases nowadays. This remarkable improvement can be attributed solely to technical improvements in the monitoring of patients during a procedure. Things like continuous pulse oximetry, end tidal CO2 monitoring, and fiberoptic-based intubation equipment have almost completely eliminated major morbidity from the profession. This is a good thing. But maybe not so good for anesthesiologists. They practice in a very algorithmic, checklist-based manner. Thus, it was relatively easy to teach their methods to CRNA's during a period when the exponential rise in operative case loads made it necessary to incorporate "anesthesiology assistants" into a practice, thereby allowing one attending physician to cover multiple rooms. That recent studies have confirmed what everyone else in the OR already knew---that it didn't really matter who was behind the drape while a cholecystectomy was ongoing---- is hardly a surprise. The less variability in clinical excellence one sees from certain specialists, there seems to be a commensurate decrease in perceived prestige. In other words, one's individual reputation as a doctor can be paradoxically harmed when the overall complication rate of your chosen specialty is so low. You are seen as a mere "cog in the machine", a cog that could easily be interchangeable with another doctor or, in this case, a CRNA.

Anesthesiology represents the easiest target. But don't think that the other specialties are exempt from possible onslaught. The more specialized we become as doctors, and the less we emphasize and reward doctors who focus on a holistic approach to medicine (primary care, internists, general surgeons) the easier it becomes for the federal government to replace those pricey specialists with back door, non-MD options who happen to be much less expensive. Imagine an "certified orthopedist" training program that one could enroll in directly out of college with a bachelors of science. You then spent the next three years doing nothing but learning musculoskeletal anatomy/pathology and practicing the basic orthopod operations in virtual reality and on actual patients. Perhaps actual orthopedic surgeons could be enticed to head up such a training program so that these ortho technician graduates learned their techniques from the best. Further imagine that research papers would be published demonstrating equivalent outcomes no matter who performed your knee replacement, MD or ortho technician.

It isn't difficult to see where all this is heading. The cost of healthcare must be controlled to prevent bankrupting our country. Medical school graduates overwhelmingly opt out of primary care and internal medicine. If you can't force or entice our brightest students to stop applying for derm and ortho and radiology residency slots, then maybe you can at least give them a little competition for that business from non-MD sources....

18 comments:

Bongi said...

i couldn't help noticing that it costs more than six times as much to train an anestheologist as a nurse anesthetist yet they only earn twice as much. i interpret this that they are six times better and are actually sorely underpaid.

anaesthetics can be quiet and even boring, but when things go wrong, and they occasionally do, the difference between a good anaesthetist and a mediocre one is the difference between life and death. and that isn't even taking into account someone who only has one sixth the training.

i conclude two things. let me never need an operation in america and maybe americans should consider surgery in south africa as a safer alternative.

Frank Drackman said...

are you just posting this cause your Cleveland Indians were mathematically eliminated yesterday?????
Hate to see what happens when the 4th or 5th best ACC team spanks your Buckeyes on Saturday...


Frank "SEC Rules" Drackman

Anonymous said...

I haven't read the article or the study they are referencing but it seems like you would need a massive study to detect a difference in outcomes, because as you said, dicey situations arise rarely.

However if I'm flying a plane, and I have the choice of having a parachute on board or just hoping nothing malfunctions in the engine, i'm taking the chute, even if it costs another 150k per year.

Furthermore, if I had any choice in the matter, I'd avoid a hospital that has unsupervised nurses giving anesthesia like the plague. Are you listening private hospitals?

Yitz said...

Hey Frank, it's going to be the best team in the ACC (also known as my 'Canes!!!!) doing the Buckeye spanking!

Anonymous said...

As a surgeon, do you care one way or the other if the person providing anesthesia is an MD or RN?

Frank Drackman said...

Might have to go into witness protection for revealin this but...
Its not so much a CRNA/Anesthesiologist thing as Male/Female.
Most CRNA's are split-tails, "Ologists" are mostly XY, or XYYY like me.
Women/CRNA's love order/predictability/routine and are perfect for your routine hernia/lap choly/boob job.
Men, REAL Men, on the other hand like RISK, and ADVENTURE, and challenges, and so what if you forgot to check the batteries in your larynoscope?? thats what the Surgeon's there for.
We wanta do the Sitting Crani's on the 600lb Elephant Boy, with a history of Malignant Hyperthermia, Tracheal Stenois, and allergy to all known Anesthetic Agents.
Your average XX CRNA will run away faster than Wisconsin Senator Feingold did from the Presidents (Peace be upon Him) visit the other day...
anyway, I've got a day of Boob jobs comin up.

Frank

Buckeye Surgeon said...

Anon-
I'll be honest, the reason why I dont care who is behind the curtain on my "routine" bread and butter cases is that the anesthesiologist is HARDLY EVER THERE anyway. I see the attending at the beginning of the case and before the ET tube is taped in place, he/she has bolted the room.

Again, this turf battle is both a function of the nature of the practice of anesthesiology and also the fact that MD anesthesiologists have opened up their own walls to non-MD technicians in an attempt to cover more OR rooms and drive up earning potential.

Bongi said...

as a surgeon i care who is on the ether side. here the gas monkey stays put throughout the procedure and will pick up any eventuality instantly. i would not be happy letting a nurse run the anasthetic, not even a small part of it. i would be severely pissed off if the anesthetist left the room during an operation. i'm astounded to see it seems to be standard practise in america. i truly wouldn't have even considered it as a possibility.

Resident Anesthesiologist Guy (RAG) said...

We have, unfortunately, been killing ourselves. Now that we run so many ORs, many anesthesiologists are torn between several rooms and, unless there's real difficulty, will often head to their next room or see the next patient to keep the OR flow moving smoothly. CRNAs have been helpful to me in many situations, as a new resident last year especially, but I wouldn't EVER think that they're equivalent to an MD/DO.

To add to this, in 10 years or so I think we'll be seeing some more problems arise. The CRNA schools are starting to let in substandard nurses, with very little experience (and some no longer require ICU experience). I think it will start to manifest itself. That or the MD's will be moved out to such a degree that only the worst of the worst medical students will match in anesthesia (like 20 year's ago when anesthesia was "doomed").

As a resident, I find the whole topic quite demoralizing, though.

Anonymous said...

Bongi,
Here in the states it's about the money honey. These days it seems more than ever, "selling out" is an acceptable option. In fact, not selling out can be seen as a missed opportunity/failure these days as in, "You idiot, you didn't sell out?!"

-SCRN

Kellie MD surgeon said...

Before moving to rural america where we have only CRNA's I thought that only Anesthesologist should be the lead in giving anesthesia. Working where I do now, CRNA's here are excellent. Remember, these folks have to have worked in a critical care function prior to enrolling in CRNA school. There are many many ICU/ED nurses that pick up on the little things prior to the MD's. They also know their limitations. If they feel a case is beyond their capabilities (person with severe aortic stenosis for example) they will discuss teh case and if necessary, we will transfer them to the "big city". I've known more MD anesthesiologist that I wouldn't want giving anesthesia to my patient than CRNA's that I would feel the same way about.

Anonymous said...

If the anesthesiologist is HARDLY EVER THERE, who is monitoring the patient? If the patient starts dying for some reason, do you have to yell for the anesthesiologist to come back?

Frank Drackman said...

annonymous:
Thats what the Alarms on the monitor are for.


Frank

halfmd said...

Don't forget that the most important part of those monitors is learning how to turn them off.

Daniel F. Kane said...

Back in the day...doctors took care of patients. Now,and it has been like this for some time, "physician extenders" of various sorts are in play CRNA, PA, NP and midwives.

It is not surprising, that CRNAs do well with CRNA cases - just like midwives, cases are cherry picked for them for their acuity and relative simplicity.

This motivated anesthesiologists to "supervise" and not practice, cover and bill for several procedures simultaneously.

Either their greed or business savvy precipitated this unintended consequence of suggesting, maybe even proving that a physician in anesthesia is not routinely necessary, a boot strapping ICU grad school nurse is sufficient.

Anonymous said...

CRNA, MD, DO I don't care just get the freakin' work done and stop whining. I have some great friends who are anesthesiologists, but I gotta say if you can't prove you're better....get outta the kitchen. Show me the studies and we can buy into the MD only for anesthesia thing.

Frank Drackman said...

CRNA's do the same cases MDs do, more actually, and where I work they do Crani's, Open Hearts, Transplants, and the most dangerous of all......
GYN cases, seriously, OJ could learn some lessons from these guys.

Frank

Anonymous said...

"CRNA's do the same cases MDs do, more actually..."

This comment says it all as it makes no sense whatsoever.