A hospital in Wisconsin made an announcement this week that startled me. The hospital leadership has fired or severed ties with all of its anesthesiologists and replaced them with certified registered nurse anesthetists (CRNAs).
As a former hospital administrator in the 1990s, I’m well-acquainted with the cost-cutting gambits that many hospitals will take, even at the expense of quality of care and patient safety.
Decades ago, hospital and insurance bean counters figured out that physician assistants (PAs) and nurse practitioners (NPs) were far less expensive to pay than doctors. Back then, PAs and NPs were referred to as physician extenders and worked in tandem with doctors. PAs and NPs were assigned responsibility for routine medical needs in primary care practices, things like colds, earaches, sore throats. This allowed practices to see more patients and freed up physician time for more complex patients and medical needs.
Later, PAs and NPs took on additional roles and were called mid-level providers. It’s now common for PAs and NPs to handle post-operative rounds for surgical and neurosurgical patients. It’s up to them to spot issues of concern with their patients and to know when they need to call in a physician or surgeon for help.
Over the years, the financial motivation spread to PAs, NPs, and nurse anesthetists, and their lobbying groups. They funded biased studies that concluded that their quality of care was equivalent or better than that of physicians, who generally have far more training.
To be clear, I’m not trying to diminish the important role that PAs, NPs, and CRNAs play in health care. They're competent to provide health care services within their training, licensure, and experience. When they try to take on responsibilities beyond their training and competence, though, it’s a danger to patients. That’s why I believe that some PAs, NPs, and CRNAs—with the cooperation of hospital and practice group leaders—are selling patients a phony bill of goods.
There’s nowhere that this is more evident than in the complex, demanding field of anesthesia care.
Anesthesiology has traditionally been the highest paid medical specialty in health care. There’s a reason for this. It requires significant training. Anesthesiologists are airway experts who know how to administer anesthetic medications to put you to sleep and bring you back safely. They’re also experts in critical care medicine.
CRNAs don’t have equivalent training and experience. According to the American Society of Anesthesiologists, physician anesthesiologist have 12,000–16,000 of clinical patient care in their curriculum, while CRNAs have just 1,650 hours. That lack of additional training that makes the average CRNA less able to handle an airway or cardiovascular emergency. Anesthesia emergencies are such that even a short delay in rendering the correct medical response can mean the difference between life and death, or brain injury and recovery.
Until recent years, Medicare and third-party health insurance guidelines have required CRNAs to be medically directed or medically supervised by an anesthesiologist who was immediately available to handle an emergency.
When it's my family member going to the operating room (OR), I consider neither model acceptable. I’m not interested in hoping that the anesthesiologist might be immediately available to respond to an emergency in my operating room, when he or she’s simultaneously overseeing:
• Medical direction model: 4 ORs with different CRNAs running anesthesia simultaneously.
• Medical supervision model: 5 or more ORs with different CRNAs running anesthesia simultaneously.
That’s why I'll always insist on a physician/anesthesiologist-only model. This takes some advance planning and personal advocacy because it’s not the way virtually any hospital works on a routine basis.
I was with a family member at Houston Methodist Willowbrook Hospital a few years ago who was having a cholecystectomy (gallbladder) around 3:00 p.m. on a weekday. When a nurse brought in the informed consent paperwork, the small print said that a CRNA would be providing the OR care. We declined and asked to see the anesthesiologist. You should’ve seen the look on the nurse’s face. Fortunately, the one and only anesthesiologist who was still on duty agreed to handle our case, and everything turned out fine. To be fair, it would've probably turned out the same way with a CRNA involved because there were no intraoperative complications. We just weren't willing to take the risk, though, in case they ran into trouble in the OR for this routine surgery.
From my experience in handling many anesthesia medical malpractice cases, I have these take aways to share:
• CRNAs are a lot cheaper than anesthesiologists for hospitals and surgery centers to hire.
• Most CRNAs lack equivalent or comparable training to most physician anesthesiologists for handling anesthesia emergencies.
• When there’s an OR emergency, most CRNAs panic and focus on getting the anesthesiologist into the OR for help.
• In medical malpractice litigation, most CRNAs subtly shift blame on anesthesiologists involved in medical direction or supervision.
• Regardless of what misinformed legislatures and misguided hospital administrators decide regarding the CRNA scope of practice, patients have the right to ask and know with 100% certainty who will be providing their anesthesia care in the OR before their put to sleep. Just ask! And ask anesthesia providers about their training, experience, and outcomes.
If you’ve been seriously injured because of inadequate or botched anesthesia care in Texas, contact a top-rated experienced Texas medical malpractice lawyer for a free consultation about your potential case.
