Why Can’t We All Just Get Along?

flying cadeuciiAmerican anesthesiology reached a significant milestone last year, though many of us probably missed it at the time.

In February, 2014, the number of nurse anesthetists in the United States for the first time exceeded the number of physician anesthesiologists. Not only are there more nurses than physicians in the field of anesthesia today, the number of nurses entering the field is growing at a faster rate than the number of physicians. Since December, 2012, the number of nurse anesthetists has grown by 12.1 percent compared to 5.8 percent for physician anesthesiologists.

The numbers—about 46,600 nurse anesthetists and 45,700 physician anesthesiologists—reported in the National Provider Identifier (NPI) dataset for January, 2015, probably understate the growing disparity. Today, more and more physicians are leaving the front lines of medicine, many obtaining additional qualifications such as MBA degrees and embarking on new careers in hospital administration or business.

Physician anesthesiologists can expect that fewer of us every year will continue to work in the model of personally providing anesthesia care to individual patients. Clinical practice is likely to skew even more toward the anesthesia care team model, already dominant in every part of the US except the west coast, with supervision of nurse anesthetists and anesthesiologist assistants.

So why does the level of animosity between physician anesthesiologists and nurse anesthetists seem to be getting worse, even as the care team gains greater prominence? Does the anonymity of the Internet bring out the worst in everyone and make civilized discourse impossible?

Anesthesiologist assistants (AAs), of course, are to anesthesiologists what physician assistants are to physicians in other specialties. They are under the jurisdiction of medical boards, not of nursing boards, and are firm supporters of anesthesiologists. In contrast, the website of the American Association of Nurse Anesthetists (AANA) states that nurse anesthetists “collaborate with other members of a patient’s healthcare team: surgeons, obstetricians, endoscopists, podiatrists, pain specialists”—a list which pointedly excludes physician anesthesiologists.

Perhaps increasing downward pressure on payments and tough competition among hospitals are worsening the strain on anesthesia practitioners of all stripes. But in an era where healthcare professionals are faced with onerous new rules and regulations on a daily basis, and report alarming levels of burnout, does it make sense for groups with so much in common to be permanently at odds? Wouldn’t they do better as allies? In the field of anesthesia, why can’t physicians, nurses, and AAs just get along?

The physician exodus from clinical care

Fee-for-service payment won’t disappear overnight, but its predominance is shrinking. That fact makes direct delivery of anesthesia—squeezing the bag—less and less appealing to physicians as a means of earning a living.

Health and Human Services (HHS) Secretary Sylvia Burwell announced in a press conference on January 26 that HHS has set a goal of tying 30 percent of Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs), by the end of 2016, and tying 50 percent of payments to these models by the end of 2018.

Just two days after the HHS announcement, a group of the top US health systems and payers announced the formation of the Health Care Transformation Task Force, a private-sector alliance that aims to accelerate the transformation to value-based care. Payers involved include Aetna and Blue Shield of California. The alliance plans to improve the ACO model and develop a standard system for bundled payments.

To survive the transition to bundled payments or other shared saving arrangements, physician anesthesiologists see the need to expand their sphere of influence outside of the operating room and take on leadership roles. Recognizing that fact, 178 participants signed up for a new and very successful leadership pre-conference, organized by Joseph Szokol, MD, MBA, JD, and Sam Wald, MD, MBA, at the ASA’s 2015 Practice Management meeting.

Medical students are recognizing early that clinical care may be turning into a dead-end trap, with endless production pressures and dwindling returns. Increasing numbers of medical students are entering joint MD/MBA programs. The Association of MD MBA Programs website lists 54 joint programs in the US, and two more in Canada. A Sept. 29, 2014, article in The Atlantic, “The Rise of the MD/MBA Degree”, reports that more than half the programs started after the year 2000. A number of medical schools also offer dual programs in medical informatics, biomedical engineering, and public health.

The new Surgeon General of the United States is perhaps the most highly visible holder of MD and MBA degrees to date. Dr. Vivek Murthy earned his combined medical and business degrees from Yale, and worked at Brigham and Women’s Hospital as a hospitalist. Soon, he reduced his clinical practice as his interests turned in other directions, and in 2008 he founded an organization called “Doctors for Obama” to mobilize the medical profession to support the Affordable Care Act. At 37, he became the youngest-ever Surgeon General.

Anesthesiology training programs are expanding their fellowship offerings beyond the traditional clinical choices. The Massachusetts General Hospital now offers a 12-month fellowship in “Perioperative Administration”, designed to offer “formal, hands-on training in the management of all aspects of the perioperative environment, particularly within a large health care system.” The University of California at Irvine, which has become a bellwether in the Perioperative Surgical Home model, offers a 12-month fellowship in “Perioperative Medicine” to “train and prepare the anesthesiologist leaders of the future.”

Many physicians are going back to school for MBA degrees and healthcare administration certificates, hoping for positions as hospital administrators, pharmaceutical executives, department chairs, consultants, or government regulators. Business schools and other organizations such as the American College of Physician Executives have been quick to establish executive programs and online courses geared toward the MD market.

The NPI dataset probably overestimates the number of physician anesthesiologists who are in active clinical practice, and the data can’t pinpoint how many of those are planning their exit strategy. The “baby boomer” generation of physicians is starting to retire, and, as a demographic, younger physicians tend to work less.

With these forces in play, the anesthesia care team model seems certain to become the predominant way that American anesthesia care is delivered. There will be increasing numbers of nurse anesthetists and anesthesiologist assistants, and relatively fewer physician anesthesiologists, fully engaged in direct operating room care.

Online incivility

It’s good to have back-up in tough clinical circumstances. Just as a passenger jet has a pilot and a co-pilot, it makes sense for anesthesia care to involve two individuals who know the patient and the case. Sometimes a fresh set of eyes can spot a problem that has been overlooked, which is why a coffee break during a long case can be a good safety measure.

In many anesthesia practices, physician anesthesiologists work with nurse anesthetists as well as with anesthesiologist assistants. Occasional personality clashes may arise, but for the most part collegiality prevails. As one nurse anesthetist wrote in an online forum, “I love my anesthesiologists and CRNA friends…To all: Let’s continue to strive to provide safe anesthesia for all of our patients. We do this by continuing to study and research cases and also by being cordial to one another in the OR.”

But anyone who follows online commentary can easily see how quickly the level of discourse can deteriorate when people are free to write under the protection of pseudonyms, and comments aren’t moderated. As a frequent “blogger” for websites like KevinMD and The Health Care Blog, I’ve had ample opportunity to see just how uncivil the comments can get. The level of hostility between some nurse anesthetists and physician anesthesiologists can come as a revelation.

An article I wrote for KevinMD in support of physician supervision of nurse anesthetists drew a number of heated counterarguments. One of the more printable comments called the article “fear mongering”, and said, “Look, if you would just admit for once this is just about business and protecting your wallets I could at least understand it.” The AANA weighed in with the comment, “Supervision is not for CRNA practice. Supervision is for reimbursement of Medicare part A (facility charges) only. Quit twisting reality.”

The disclosure that a board-certified anesthesiologist (though not an ASA member) was present during the endoscopy that preceded Joan Rivers’ cardiac arrest elicited considerable glee among the nurse anesthesia online community. “Too bad there wasn’t a CRNA in the room to ensure Ms. Rivers was safe and alive,” one writer crowed. Another wrote, “When seconds count, I want a CRNA doing my anesthesia.” To his credit, a nurse anesthetist writing under his own name had the courtesy to reply, “That crap brings my profession down. Quit it.”

Unfortunately, physicians don’t always resist the temptation to write anonymously what they would never publish under their own names. The website Sermo often publishes unexpurgated critiques that physicians write concerning “noctors”—the derisive term they apply to nurses practicing independently. One anesthesiologist, in an online discussion of the Joan Rivers case on The Health Care Blog, calls nurse anesthetists “arrogant and cocky” and concludes, “Let the replies begin!”

Understanding the history

Why highlight hostility between some nurse anesthetists and physician anesthesiologists? Why focus on the fact that this hostility often extends from nurse anesthetists to AAs? I think the best reason to examine the ill will closely is to understand the history behind it, and, in time, to move past it. Long-standing grudges do no one any good.

Fifty or more years ago, nearly all physician anesthesiologists were men, and nearly all nurse anesthetists were women. Many of those nurse anesthetists would probably have attended medical school and become excellent physicians if the opportunity had been open to them.

In the 1970s, those ratios began to change. Young men in American military service began to attend nursing school in larger numbers, and many became nurse anesthetists. The AANA now estimates that more than 40 percent of nurse anesthetists are men. At the same time, more women began to gain admission to medical school. By 2014, the American Association of Medical Colleges reported that 47% of medical school graduates were women, though women comprised only 33 percent of the applicants for anesthesiology residency positions.

Experienced nurse anesthetists have little opportunity for advancement in their careers unless they move into administration. It’s easy to see how they could resent supervision by physicians many years their junior. This resentment could be compounded if some anesthesiologists indeed spend their time, as one nurse anesthetist put it in an online comment, “sitting in the office, watching their stock portfolios or their favorite TV show while someone else stays in the operating room actually taking care of the patient.”

I wish my job could be that easy! Most of my patients undergo complex operations and suffer from multiple medical problems. They require my constant presence in the operating room, and all the knowledge I can bring from medical school, four years of residency and fellowship training, and endless hours of continuing medical education.

Most patients assume that their anesthesia care will involve a physician, and prefer it that way. They express surprise at the idea that nurses could practice in any capacity without physician oversight. None of the leading hospitals in the US—academic or private—is staffed with nurse anesthetists working without supervision. The majority use the anesthesia care team model, under the leadership of anesthesiologists.

The rationale for the creation of the AA profession in the 1960s was the shortage of anesthesiology professionals. The goal was to create a new master’s level program that would enable graduates to deliver anesthesia care under the direction of a physician anesthesiologist. The concept and the curriculum were designed along similar lines to the training of physician assistants. But from the beginning, the fledgling anesthesia profession was strongly opposed by the AANA, and their lobbying has stymied attempts to license AAs in several states.

Nurse practitioners and physician assistants work alongside each other in many medical and surgical practices without competition or animosity. It’s hard to see why this collegiality has been so difficult to achieve for nurse anesthetists and AAs, though many practices report that once the first AA is hired, the opposition from nurse anesthetists dissipates quickly. Money is probably not the major factor, as salaries for AAs and nurse anesthetists nationally are similar. Since there are fewer than 1700 certified AAs in the US today, they hardly pose a serious competitive threat to the nearly 47,000 nurse anesthetists.

Increasing demand for anesthesia care

In the 1990s, with the advent of minimally invasive surgery, some people argued that the demand for anesthesia services would decrease, and that we wouldn’t need as many anesthesia professionals. That forecast turned out to be completely wrong. As anesthesia becomes safer and surgical techniques improve, patients who previously wouldn’t have been considered suitable candidates now undergo anesthesia safely every day. Minimally invasive techniques and the invention of new procedures have multiplied the demand for anesthesia services.

There’s plenty of work in the anesthesia field for everyone—physicians, nurses, and anesthesiologist assistants. The anesthesia care team model is safe, cost-effective, and shouldn’t be controversial. In most medium-size and large hospitals, nurse anesthetists and physician anesthesiologists work comfortably side by side every day. When I was a junior faculty member in my first position after residency, experienced nurse anesthetists at Duke University Medical Center—notably Tinkie Smith and Tede Spahn—taught me a great deal and smoothed my transition into practice. I’ll be forever grateful for their wisdom, friendship, and support.

As physician anesthesiologists expand our role outside the OR, the care team approach will become even more prevalent. It’s incumbent upon all of us to continue the integration of AAs into the care team model, and to work toward eliminating bad blood between nurse anesthetists and other anesthesia professionals. Our patients deserve better.

Karen Sibert, MD is an anesthesiologist based in Los Angeles and a frequent contributor to THCB. She blogs at a penned point. 

14 replies »

  1. Calling us “anesthesia nurses” is just another way physicians try to undermine our credibility. I’m a Nurse Anesthetist or CRNA (not NA). If you respect the people you work with, they won’t want to get rid of you.

  2. Karen;
    Regarding the “opt out” status which you refer to. Remember that this is purely a Medicare billing issue. Small rural hospitals who sell surgical services must “opt out” of the federal rule for for physician supervision of anesthesia services so that they will be paid for anesthesia services on Medicare patients without having to hire anesthesiologists and without having to put the surgeons on the hook for supervising the nurses.
    This “opt-out” status does not indicate that anyone in the state has determined that anesthesia care without medical supervision is safe. It simply allows small rural hospitals to make money from Medicare by providing surgical services with unsupervised anesthesia care.

  3. From a nursing standpoint you just don’t want to deal with all the crap. If you’ve worked for 15 years as an anesthesia nurse it’s degrading to be talked down to by the much younger anesthesiologist.

  4. To pmlucas, in response to the comment that anesthesia care inevitably declined, causing surgery volume to decline, leading to hospitals and patients suffering, so anesthetists could have independence… I don’t even know how to respond to this other than to leave you with one of my favorite quotes… “That which can be asserted without evidence, can be dismissed without evidence”

  5. We used to all get along quite well. Until the anesthesia nurses’ professional society became militant about their perceived ability to practice without the supervision of an anesthesiologist.
    I watched a wonderful team practice slowly disintegrate as the nurses used their time in the OR espousing the idea that nurses can do the anesthesia just fine without supervising anesthesiologists. This successfully undermined the credibility of the anesthesiologists eventually resulting in a nurse dominated practice with one or two nominally supervising anesthesiologists. The anesthesia nurses surely felt pleased with themselves for obtaining their long sought independence. But as the quality of care inevitably declined, and the larger community learned of it, the surgery volume declined. Patients and the hospital suffered so that a few nurses could have the privilege of “independence”.
    Many anesthesiologists recognize this problem and thus struggle to maintain nurse-free practices even though it would be slightly more lucrative to have anesthesia nurses in the ORs. By the way, the anesthesia nurses salary requirements are such that the economy of the team approach is only favorable when the supervising ratios are at the limits of safety.
    If the anesthesia nurses would abandon their “we don’t need no stinkin’ doctors” philosophy, we could all get along. And patients would benefit as well.

  6. One consideration as to the growth rates of the respective professions is simply demand driven by cost…hiring one physician anesthesiologist to be supported by 2-3 AAs or NAs is often a much lower cost proposal than hiring two physician anesthesiologists. Add to that the fact that I am now able to cover 35%-50% more cases with a lower cost of care delivery.

  7. This is a smart, thoughtful piece that speaks to relationships throughout health care, not just the “animosity between physician anesthesiologists and nurse anesthetists.” At its core this is about respect for people. The Toyota Production System is widely seen as a management method; a collection of lean tools and principles. And in one sense it is surely that. But the lean enterprise rests upon a foundation of respect for people and learning how to do so in a complex organization requires some training. We assume that highly educated people know how to treat one another in a respectful way. Very often, however, this is simply not the case. The arrogant, condescending physician disliked by nurses may not realize the impact he/she is having on other people. Respect for people training at Virginia Mason Medical Center in Seattle is one of the most impactful steps taken in the 14 year lean journey at Virginia Mason. (Link below to Virginia Mason blog post re: their respect for people work.)

    Paul O’Neill has defined respect in a way I find compelling. He says that great organizations are ones where employees answer yes to three questions:
    – Can I say every day I am treated with dignity and respect by everyone I encounter without respect to my pay grade, or my title, or my race, or ethnicity or religious beliefs or gender?

    – Am I given the things I need — education, training, tools, and encouragement – to develop my full potential so I can make a contribution to the organization that gives meaning to my life?

    – Am I recognized and appreciated for the work I do?’’

    If the answer was yes to all three of these questions among everyone working on the anesthesia team, then, in answer to Karen’s question, many more people would be getting along. One other point. She notes that many “physicians are going back to school for MBA degrees and healthcare administration certificates, hoping for positions as hospital administrators, pharmaceutical executives, department chairs, consultants, or government regulators.” Effectiveness in any of these roles would be increased I suspect if the physicians were to study the lean respect for people work and apply Paul O’Neill’s three questions.


  8. At first glance, i thought this article was written in Nigeria where there is constant bickering between physicians and nurses. I think teamwork is a critical aspect of quality healthcare. No one profession can do it alone.

  9. In response to Karen Seiberts post, the individuals who are sued depend on the law firm filing the suit. I am a CRNA and have been sued for a severe surgical complication I discovered, postoperatively. I would suspect that a surgeon, anesthesiologist, and a CRNA may be sued for anything that happens to a patient, if they were involved in the care of that patient during the event, the diagnosis, or the treatment. In my experience, during the litigation process, the lawyers go after the individuals that have a malpractice policy, the biggest of which is always the facility in which the event occurs (hospital, surgery center). The best way to not be sued is to work with a team that keeps our patients safe and happy! Any feedback is welcomed.

  10. Not a simple question, and one really for the lawyers. If a nurse anesthetist, a physician assistant, a resident, an AA, or any other practitioner is working under my supervision or medical direction, then the ultimate responsibility is mine. Typically, physicians in private practice carry their own malpractice insurance, and a nurse anesthetist, for example, would have liability coverage provided by the employer, usually the hospital or outpatient center.

    PAs and AAs always practice under physician medical direction, though they may have considerable autonomy on the day to day level.

    In states like California, which have “opted out” of requiring any physician supervision of nurse anesthetists, it isn’t clear to me at all what happens in the event of a lawsuit where a nurse anesthetist was practicing without physician supervision. Clearly if no anesthesiologist was involved in a given case, there is no liability there. I would expect that both the surgeon and the facility would be sued as well, but I have no idea if a “captain of the ship” doctrine is applicable in instances of independent practice by advanced practice nurses, whether midwives, NPs, CRNAs, etc. It would be interesting to have any attorneys in the audience provide their perspective.

  11. I’m also curious to understand how this information is conveyed to patients – specifically information on risk. Risk is a big deal here.

    How do any patients feel about this? If you were doing a minor case, Would you be comfortable having a nurse or a PA handle your case?

  12. Does the mal-practice insurance premium level reflect the skill of each of these professionals? Will it determine who survives in the future?…by presenting higher costs to the most unfit practitioner?

  13. Quick question for you Karen, what does liability look like for the PAs and the nurses? Who is the captain of the ship in these cases? The surgeon? The facility?

    I’m curious to know how nurses and PAs feel about this. Should they be held liable?