Opinion
Access to anesthesia care, without patient safety, isn’t a solution
Image by PeopleImagesOPINION – Most policy discussions about improving health care in California start with talking about “access” – the lower the costs, and the more people cared for…the better. But that plan only works if, alongside access, quality of care improves with it. Access to anesthesia care, without safety, isn’t a solution.
This is especially true when undergoing surgery. We place trust in the doctors (anesthesiologists) who put us to sleep, and the doctors (surgeons) who operate on us, confident they are equipped to keep us safe and make sure we wake up safely with the best possible outcome. Yet some advocates have pushed to replace anesthesiologists, who are physicians who undergo 12,000-16,000 hours of anesthesia training, with nurse anesthetists (CRNAs), despite evidence that anesthesiologist-led care decreases the risk of patient death and complications. Further research found that patients are far more likely to have an “unexpected disposition” (admission to the hospital or death) if their anesthesia was solely provided by a nurse anesthetist rather than a physician who is an anesthesiologist.
As physicians who undergo 4 years of college, 4 years of medical school and 4+ years of anesthesiology residency training, anesthesiologists have the advanced training and expertise to make difficult decisions and diagnoses that nurse anesthetists (CRNA) cannot. For many cases and many patients – CRNA care is absolutely appropriate and safe. But there is an essential role for physician-led anesthesia care in every facility – so that a physician is available to make difficult diagnoses, treat patients with complex conditions, and handle life-threatening complications that may arise during a surgery. To be clear, nurse anesthetists are a critical part of the anesthesia care team, but the skills and level of training for nurse anesthetists are not the same as, and cannot replace, a physician’s advanced training and skill set.
It is very important that we do not create a tiered system of care, where only certain communities have access to physicians, while rural or less wealthy areas only have access to nurses. All patients – no matter their race, income, or demographics – deserve access to physician-led care: that is the standard of care amongst California’s major health systems such as the University of California medical centers, Stanford Medical Center, and Kaiser Permanente.
It might sound obvious that people are generally healthier when cared for by doctors. But it is worth remembering, given that some political groups advocate for stretching staffing resources in the name of expanding access. We cannot condone or encourage a system that sanctions unequal access to physicians and unequal outcomes for patients. Instead, let’s focus on addressing the many inequities that already exist to improve health outcomes for minority and disadvantaged patient populations. Stretching healthcare access while undermining safety will only make existing problems worse.
Unfortunately, we recently saw proof of this with reported harm to patients in Modesto and documented in investigations led by the California Department of Public Health (CDPH). Regulatory inspections of Stanislaus Surgical Hospital were highly critical of how the facility managed medical emergencies and indicated concerns about how the delivery of anesthesia by nurse anesthetists (CRNAs) was being utilized in patient care without physician/anesthesiologist leadership. There were alarming findings regarding the risk of patient harm, and inspectors declared that the problems were serious enough to pose a major threat to patient safety with issuance of “immediate jeopardy” to the hospital.
This situation should serve a big wake-up call for healthcare facilities across the state. Healthcare administrators must enact strategies to protect patients and ensure compliance with existing patient safety regulations and scope-of-practice rules for different providers. Otherwise, patients pay the price.
By providing access to proven, well-designed physician-led anesthesia care — with transparency about the team providers and responsible deployment of those professionals in the right roles — we can safeguard patient safety when seconds count and minutes matter. Let’s be clear — this isn’t a turf war or political game — it’s about ensuring patient safety for all Californians in all communities. There is nothing more important than keeping our patients safe while undergoing anesthesia care for their surgery.
Amid conversations to improve California’s health care, remember – healthcare access, without patient safety, isn’t a solution.
Antonio Hernandez Conte, MD, MBA, FASA, is Immediate Past-President, California Society of Anesthesiologists.
Want to see more stories like this? Sign up for The Roundup, the free daily newsletter about California politics from the editors of Capitol Weekly. Stay up to date on the news you need to know.
Sign up below, then look for a confirmation email in your inbox.
The bigger risk to patients is when an anesthesiology assistant is left to care for a patient while anesthesiologist is not present for the case. CRNAs have extensive education in anesthesia and critical care prior to just working in anesthesia. I fear when AA s provide care. That is where this article should center on not on highly educated CRNAs.
Dr. Conte has conveniently left out the fact that reports indicate a surveyor contracted by the CDPH (a physician anesthesiologist) misrepresented state and federal laws regarding CRNA practice. This single individual, who entered a facility with a clear agenda to attack and plant seeds of doubt concerning CRNA practice, managed to issue three biased surveys, resulting in severe disruption of care. This personal agenda by the CDPH physician anesthesiologist surveyor against CRNA practice led to the unnecessary cancellation, delay, or transfer of over 1,000 surgeries, the majority of whom were Medicare and Medi-Cal beneficiaries. Clearly the financial interests of a few physician anesthesiologists in their desperate ploy to hold on to a feeling of supremacy is more important than the surgeries of over 1,000 patients, especially those with Medi-Cal and Medicare reimbursement and not cash payment for services rendered.
CRNAs are highly trained, educated, and qualified anesthesia experts. They provide 50 million anesthetics per year in the United States and work in every setting in which anesthesia is delivered, including traditional surgical suites, ambulatory surgical centers, critical access hospitals, and offices of dentists, podiatrists, ophthalmologists, plastic surgeons, and pain management specialists. CRNAs are also the primary providers of anesthesia in rural America, where they ensure access to anesthesia, obstetrical, and pain management services for populations that would otherwise have to travel far distances from their homes for treatment.
When the cases in Modesto were canceled, physician anesthesiologists did not step in to fill the gap of providers. Dr. Conte has left out the fact that four counties of California are served only by CRNAs, and he offers no solution to the fact that his plan for “physician-led” care is lacking one major component- physician anesthesiologists. Dr. Conte is desperately clinging to a care model for anesthesia that is the least cost efficient and lacks the physician providers necessary to meet the needs of Californians.
Yes, Californias deserve safe anesthesia care. CRNAs’ safety record is irrefutable. Their safety record is backed by research, not opinion. CRNAs have practiced in California for over 30 years and since then, education requirements for CRNAs have increased dramatically so that all CRNAs now graduate with a doctoral degree. CRNAs undergo six to eight years of rigorous academic and clinical training and must pass a national certifying exam. Dr. Conte ignores the fact that graduation and residency requirements are equivalent for programs training nurse and physician anesthesiologists and that physician anesthesiologists often train CRNAs during their anesthesia residency.
Dr. Conte is drumming up fear about the safety of CRNA practice to desperately project the idea that physician anesthesiologists are superior to nurse anesthesiologists. The fact is, physician and nurse anesthesiologists are both trained, qualified and safe to provide anesthesia. However, only CRNAs are nationally board certified in anesthesia, a distinction not held by their physician colleagues. The real question is whether or not a physician or nurse anesthesiologist is willing to treat Medicare and Medi-Cal patients in rural areas of the state. Thus far, “physician-led” care just means “NO care” for thousands of Californias. Californians need anesthesia provided by safe, trained, qualified, independent and board certified anesthesia providers, regardless of their race, income, or demographics.
Dr. Conte is right, this is not a turf war. CRNAs do not want to take over physician provided anesthesia. CRNAs of California promote safe, independent care, by board certified anesthesia providers, irrespective of their practice background, to ALL of California’s residents regardless of their ability to pay or where they choose to live. We need all CRNAs and physician anesthesiologists to work to their full scope of practice to meet the anesthesia demands of Californias.
It sure seems that Dr. Conte and other physician anesthesiologists have opposing interests and fein putting the safety of patients ahead of the need to protect their “turf” in an imaginary battle they fear will effect their bottom line. Californians deserve better.
Championing CRNAs: Ensuring Patient Safety and Expanding Access to Quality Care
Dear Dr Conte,
I appreciate your dedication to patient safety and the quality of healthcare services. However, I’d like to address some misconceptions you’ve presented about Certified Registered Nurse Anesthetists (CRNAs) working independently and highlight their vital role in our healthcare system.
1. Evidence-Based Patient Safety and Outcomes
• Comparable Patient Outcomes
You may be interested to know that numerous studies have demonstrated that CRNAs provide anesthesia care with patient outcomes comparable to those of anesthesiologists. For example, a study published in Health Affairs found no significant difference in mortality rates or complications between CRNAs and anesthesiologists, whether working individually or in teams.
Source: Dulisse B, Cromwell J. “No Harm Found When Nurse Anesthetists Work Without Supervision by Physicians.” Health Affairs. 2010;29(8):1469-1475.
• Rigorous Education and Training
CRNAs are highly trained professionals who undergo extensive education and clinical experience. They are required to obtain a minimum of a master’s degree, with many pursuing doctorates, and complete thousands of hours of clinical practice. This rigorous training ensures they are well-equipped to make critical decisions during anesthesia care.
Source: American Association of Nurse Anesthetists (AANA). “Education of Nurse Anesthetists in the United States.”
2. Enhancing Access to Care
• Addressing Healthcare Disparities
By practicing independently, CRNAs significantly improve access to anesthesia services in rural and underserved areas where anesthesiologists may be scarce. Expanding the scope of practice for CRNAs is supported by major health organizations to meet the growing healthcare needs of diverse populations.
Source: Institute of Medicine. “The Future of Nursing: Leading Change, Advancing Health.” National Academies Press; 2011.
3. Economic Value to the Healthcare System
• Cost-Effective Care
Utilizing CRNAs is a cost-effective strategy that helps reduce overall healthcare expenses without compromising patient care quality. Studies have shown that CRNAs provide specialized services that offer significant economic benefits, allowing resources to be allocated to other critical areas within the healthcare system.
Source: Hogan PF, Seifert RF, Moore CS, Simonson BE. “Cost Effectiveness Analysis of Anesthesia Providers.” Nursing Economic$. 2010;28(3):159-169.
4. Commitment to Ongoing Education and Patient Safety
• Continuous Professional Development
CRNAs are dedicated to lifelong learning, regularly updating their skills and knowledge to uphold the highest standards of patient safety. This commitment ensures excellence in anesthesia care and adaptation to evolving medical advancements.
Source: AANA. “Continuing Education.”
5. Addressing Misconceptions and Specific Incidents
• Contextualizing Individual Cases
While any patient safety incident is concerning, it’s essential to avoid generalizations based on isolated events. The situation in Modesto should be thoroughly investigated, but it doesn’t reflect the overall safety record of CRNAs nationwide.
Note: Without specific details, we must be cautious in attributing systemic issues to CRNA practice based on singular events.
6. The Unique and Essential Role of CRNAs
• Scarcity of Specialized Skills
In the world of healthcare, the specialized skills of CRNAs are rare and highly valuable. The pool of professionals qualified to perform this critical role is limited, highlighting the importance of empowering CRNAs to thrive. By supporting each other, CRNAs can better protect and serve patients across all communities.
Source: U.S. Bureau of Labor Statistics. “Occupational Outlook Handbook: Nurse Anesthetists.”
• Collaboration in Healthcare
It’s important to emphasize the significance of teamwork among all healthcare providers to enhance patient outcomes. A collaborative approach that recognizes the contributions of both CRNAs and anesthesiologists is essential for delivering the highest quality care.
Conclusion
CRNAs are indispensable to the nation’s healthcare system, providing safe, effective, and accessible anesthesia care. By continuing to support and empower CRNAs, we uphold the principles of patient safety, address healthcare disparities, and contribute to a more efficient and equitable healthcare system. I encourage you to consider the evidence supporting the valuable role of CRNAs and join in fostering a collaborative environment that benefits all patients.
References
1. Dulisse B, Cromwell J. “No Harm Found When Nurse Anesthetists Work Without Supervision by Physicians.” Health Affairs. 2010;29(8):1469-1475.
2. American Association of Nurse Anesthetists (AANA). “Education of Nurse Anesthetists in the United States.”
3. Institute of Medicine. “The Future of Nursing: Leading Change, Advancing Health.” National Academies Press; 2011.
4. Hogan PF, Seifert RF, Moore CS, Simonson BE. “Cost Effectiveness Analysis of Anesthesia Providers.” Nursing Economic$. 2010;28(3):159-169.
5. AANA. “Continuing Education.”
6. U.S. Bureau of Labor Statistics. “Occupational Outlook Handbook: Nurse Anesthetists.”
By addressing these points, I hope to clarify the essential role of CRNAs and reinforce our shared goal of providing the highest quality care to all patients.
Wow! This is simply not true. As a vascular surgeon who works with both CRNAs and physician anesthesiologists, I can say with confidence that I’d be more than happy to have some CRNAs provide my anesthesia—and the same goes for some physician anesthesiologists. The key word here is some. There are excellent providers from both educational paths, and there are poor providers from both, just as you’ll find in any field—whether it’s surgeons, chefs, or mechanics. Educational background alone doesn’t define the quality or safety of a provider.
There have been numerous studies showing that physician supervision of CRNAs isn’t necessary for safety, despite what some claim. Physician anesthesiologists advocating for the anesthesia care team model often benefit financially, as they’re able to ‘supervise’ 2-4 CRNAs from a lounge in a chair and still receive payment for the work those CRNAs are doing. In my view, this is about politics and income—not patient safety.
When my own mother needed surgery, I chose a specific CRNA over other providers because I had heard from 3 surgeons that he was the absolute best choice for that specific procedure. In my practice, I’ve seen physician anesthesiologists needing help from CRNAs, and I’ve seen the reverse, with CRNAs assisting physicians. The truth is that good providers work together, regardless of their degree.
To my physician anesthesiologist colleagues who continue to insist on supervision billing, I’d say: why not do what the rest of us do—get paid for the cases you actually perform? And please, let’s stop spreading misleading information. There are many studies that contradict these claims of superiority and demonstrate no difference in patient safety between physician anesthesiologists and CRNAs working independently.
I’ll continue to advocate for CRNAs and work with any provider I’m paired with to deliver safe and effective surgical care with safe and effective anesthesia care for my patients.
Your disparaging remarks regarding CRNAs should be Beneath you. What evidence do you have to support your claim? There was a study years ago that showed Anesthesiologists providing anesthesia without CRNAs resulted in more unfavorable outcomes for patients. I noticed you didn’t mention that.
These unwarranted and self-serving attacks do nothing but jeopardize access to quality, safe anesthesia care in the most underserved communities in California. Our patients don’t deserve this, the surgeons don’t need the added hurdle to getting their cases done and our state leaders certainly are tired of the lies and scare tactics. Enough already. Let’s just all get to work doing what we were all trained to do in the first place: anesthesiology. We’re not interested in any kind of so-called “turf war”. We just want to get to work and take care of our patients.