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My Turn
A Question of Power, Money and Control?
Jay Horowitz
Publish Date: June 9, 2008
Here's the bad news: We are facing an anesthesia provider shortage, which is projected to get worse in the coming years. Here's the good news: Our heath care system allows two groups of health care providers, anesthesiologists and certified registered nurse anesthetists, to administer anesthesia to patients. But there's more bad news: Regulations like the Medicare Supervision Rule for CRNAs will do nothing to make anesthesia care safer, and will, in fact, make it more inaccessible.

The current turmoil in anesthesia has nothing to do with patient safety. It is purely about anesthesiologists' power, control, and income. Sadly, anesthesiologists have resorted to unethical tactics to try and prevent reasonable changes to the CMS rules regarding supervision of CRNAs.

Here are the facts about CRNAs:
  • Anesthesia is the practice of nursing and has been for over 100 years. Nurses were providing anesthetics long before physicians considered anesthesia a profitable specialty. No amount of revisionist history on the part of anesthesiologists will change that fact.
  • CRNAs and anesthesiologists are typically trained side by side in medical centers throughout the country. We hear the same lectures, work with the same mentors and are clinically trained in the whole array of anesthetic techniques. To argue that only medical schools provide a proper anesthesia education denies an entire body of knowledge based on research and experience presented in nursing schools and schools of nurse anesthesia.
  • All CRNAs are board certified by national exam and re-certified every two years. Many anesthesiologists never pass or even take their boards.


The Medicare Supervision Rule will simply allow physicians to receive payment for work they don't do. All too commonly in pre-op meetings with patients, an anesthesiologist implies that he or she will actually administer the anesthetic, when, in fact, he will merely be "supervising" several CRNAs in different ORs. This "supervision" often consists of nothing more than a signature on a form. Yet, for their "efforts," anesthesiologists receive at least 50 percent of the reimbursement for as many as four procedures that they "supervise" simultaneously.

I've even been involved in cases where anesthesiologists have been negligent in their primary responsibilities. Not long ago, I stepped into an OR looking for an anesthesiologist who was supposed to be managing a gall bladder case. He was nowhere to be found. As it happened, he had gone for a cup of coffee and had gotten sidetracked after striking up a conversation, leaving the patient unattended for over 20 minutes. Naturally, I remained with the patient until the anesthesiologist returned. I later reported this incident to the chief of the department but to my knowledge no action was taken in this clear-cut case of abandonment and negligence.

Thankfully, these cases are rare, but I've seen enough of them during my 14 years as a CRNA to realize that the title following a provider's name is no guarantee of clinical acumen or personal responsibility.

The Medicare Supervision Rule will have a more dangerous effect than just supplementing anesthesiologists' pocketbooks and driving up the cost of healthcare-it will limit access to anesthesia care, especially in rural areas where there are fewer anesthesiologists available. It's ironic that this law, which is being proposed in the name of patient safety, will most likely have just the opposite effect.

It is through the work of nurse anesthetists, anesthesiologists, and drug and equipment companies that modern anesthesia has become incredibly safe. To keep it that way, all healthcare providers need to put their egos aside and commit to work together to do what's best for our patients.

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