By KAREN  SIBERT, MD

American 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.