• When Physician Anesthesiologists Get Offended

    Joseph A. Rodriguez, CRNA, is a managing partner for Arizona Anesthesia Solutions, an anesthesiology group based in Phoenix, Arizona. Utilizing leadership techniques and strategies that are both old and new, Mr. Rodriguez and his colleagues have grown the group from a single office to dozens of offices, ASCs, and tertiary care centers throughout the state, with 40 FT CRNAs. Additionally, Mr. Rodriguez is the former president of the Arizona Association of Nurse Anesthetists where he’s been part of teams with a record of regulatory successes including Opting Out, the country’s first surgeon immunity statute, and establishing CRNAs of AZ PAC, which has grown to be Arizona’s top political action committee. Mr. Rodriguez resides in Northern Arizona where he maintains a clinical practice in addition his administrative responsibilities.

    What should CRNAs do when they see physician anesthesiologists complaining about CRNAs, and the AANA, assertively defending and promoting our practice? When they walk into the lounge huffing and puffing, with a printed out “CRNAs: We are the Answer” document from the AANA in hand?

    Advise them to take a few deep breaths, and to help them realize it’s not “either/or”, it’s”both/and”.

    The AANA’s Public Statement on Anesthesia Delivery in the United States conclusively defines the CRNA role. Those who seek to limit or limit competition from CRNAs are none too happy about it.

    The AANA’s Public Statement on Anesthesia Delivery in the United States conclusively defines the CRNA role. Those who seek to limit or limit competition from CRNAs are none too happy about it.

    Recently, a number of prominent members of the American Society of Anesthesiologists on Twitter posted that they felt “disparaged” by the new “We Are the Answer” document from our association. They lauded one another on the medical Twittersphere, it was quite the rage for a while – with statements aplenty about how CRNAs should know their place.

    What radical statements does “We Are the Answer” make?

    Mostly things that every CRNA already knows.

    It contains crazy ideas such as identifying models like physician-only, CRNA-only, or some model of a team. Also the absurd idea that CRNAs and anesthesiologist assistants are not interchangeable. The document touches on the idea that compensation of physician anesthesiologists is arguably propped up by policies designed by physician anesthesiologists (personally I wasn’t too keen on this section, being more of a free-market person myself). And perhaps the most radical – that CRNAs are experts, along with our physician and dentist colleagues.

    But of course, the ASA response to CRNAs is nothing new. The ASA has systematically attempted to control, limit, or eliminate CRNAs for the last century. At one point, a prominent ASA leader even labeled CRNAs an “economic crime”. And when that argument failed, they turned to unproven safety concerns, which they’ve been using for the last few decades. But, their plans have been clear for a long time. Perhaps they thought we weren’t noticing?

    Bottom line: the ASA has been offended at every single action individual CRNAs, and the AANA, have ever taken to promote our profession – including existing.

    “I’M DEEPLY OFFENDED!”

     “I’m offended, and I don’t think most CRNAs are on-board with this position.” was also seen in the last few days from physicians on Twitter.

    This is a form of “gaslighting” – whereby some physicians try to sow doubt among the CRNA community. Subtle hint: we’re not buying it. The AANA has a significantly higher membership percentage than the ASA, and CRNAs in ACT model are the ones who suffer the most from ASA advocacy on AAs – and it is the AANA who fights against those anti-competitive measures.

    It follows then, that the CRNAs whose careers have been negatively impacted by ASA policies, or whose opportunities have been limited – well, they likely feel a tiny bit worse than the offense taken from a philosophical statement. Perhaps these physicians fail to see the decades of offense from their own organization.  So, I’m glad to highlight a few:

    “This is a form of “gaslighting” whereby some physicians try to sow doubt among the CRNA community. Subtle hint: we’re not buying it. The AANA has a significantly higher membership percentage than the ASA, and CRNAs in ACT model who suffer the most from ASA activities on AAs, and it is the AANA who fights against those anti-competitive bills.

    How did the ASA think CRNAs would respond to the “new” anesthetists?

    The “Anesthesia Care Team Statement” – a document that classifies CRNAs only as assistants – says we are part of an anesthesia “ team”. But in that team, CRNAs are often restricted from learning or using skills as the ASA works aggressively to limit the abilities, opportunities, and education of the members of that team (CRNAs).

    What kind of “team” is that, exactly?

    Real teams promote the abilities of everyone – so the ASA position isn’t about a team – in reality, it’s a scheme. A pretty lucrative one too, since physicians can bill 200% of their fee in a 1:4 ratio.

    Perhaps the most notable recent anti-CRNA activity from the ASA is the “Meet Your New Anesthetist” campaign – and website domains like www.anesthetist.org. (note the web address and where it takes you).

    The ASA position is a stark contrast to the AANA position, but not in how the offended Twitter-ers thought. The ASA position excludes CRNAs and labels CRNAs as assistants, whereas the AANA position includes both professions – CRNAs and physicians – as experts.

    Think about that. The ASA excludes – the AANA includes.

    So, shouldn’t it be CRNAs who take offense?

    “The “Anesthesia Care Team Statement” – a document that classifies CRNAs only as assistants to anesthesiologists – says we are part of the anesthesia “ team”. But then the ASA works aggressively to limit the abilities of the members of the team (CRNAs). What kind of “team” is that, exactly?

    Sure, someone will respond and say “I love our CRNAs! I include them as members of the team!” But they neglect to admit that they also seek to replace CRNAs on that team. Below, University of New Mexico (UNM) is a good example. 15 years ago, AAs gained the right to practice at UNM. Now, only one CRNA remains. Below is the impact of ASA advocacy on CRNAs – CRNAs slowly begin disappearing from the practice.

    This is what happens when the ASA “Team” gets into place, and when they control both regulations and practice: market control. It’s why AAs are inherently designed to reduce competition.

    This is what happens when the ASA “Team” gets into place, and when they control both regulations and practice: market control. It’s why AAs are inherently designed to reduce competition.

    “THE CRNAS ARE MARCHING ON WINTERFELL!”

    So what if the nightmare of the ASA came to pass?

    Full scope of practice. Gasp!

    Opt out. Horrible!

    How bad, exactly, would that really be for physician anesthesiologists?

    Would it be the end of MD-only anesthesia? Would it be the end of academic anesthesiology? Would the ASA plunge into a Mad-Max type scenario, living in a metaphorical professional desert? And if these changes occurred, would it take many years to see the impact?

    No.

    “Would it be the end of MD-only anesthesia? Would it be the end of academic anesthesiology? Would it take a decade or two for these things to occur?

    No.

    Let’s look at Washington.  Washington has been an opt out state for nearly 20 years.  Their laws are the most liberal in the nation for CRNAs – and yet even a cursory review reveals multiple, large MD-only anesthesia groups in the most desirable living places, like Seattle.  It appears University of Washington has not been taken over by CRNAs (they still use a fairly conservative medical direction model, prone to fraud yes, but still the ASA standard).  It seems there was no mass riot to remove the chairman, who from his bio seems quite intelligent and accomplished, but not skilled in fending off mobs – so I’m assuming there hasn’t been one.  California is in a similar position, and yet the sky is not falling and the CSA seems alive and well.

    This “end of specialty” hyperbole is used for a reason – it’s politically beneficial and motivates ASA members to express their ire towards CRNAs.

    #PATIENTSOVERPOLITICS

    I think the irony was lost on the physicians on social media.

    I think the irony was lost on the physicians on social media.

    The ASA often uses a subtle way to criticize CRNAs: take the moral high ground. The #PatientsNotPolitics hashtag showcases a new medium for an old strategy.

    Now, I have no qualms with physicians advocating for patient safety – it’s great!

    I do take issue when physicians make themselves appear to be focused on patient safety, when in reality they are making political statements with obvious competitive and economic concerns (or make statements about patient safety and do not realize the economic and competitive concerns) Let’s be clear: the debate on the safety of CRNAs – in any model – has long been over.

    Also notable about this hashtag: the ASA is arguably the most political active physician group in the world.  That’s not an exaggeration.  The ASA has assets over $100M and is currently the #1 political action committee for health professionals in The United States.

    In modern terms – this is industry version of being a “crybully” – wherein the ASA describes themselves as a victim (ie “crying”) and the sole champion of a righteous cause, and simultaneously plans political moves to eliminate (or “bully”) CRNAs.

     Political activity isn’t wrong. Just be honest about it, and don’t use patients as political footballs. Don’t appeal to moral authority when this is about competition, not safety. Doing so is a misuse of public trust.

    The ASA raises an awful lot of political money for not being focused on politics.

    “In modern terms – this the industry version of being a “crybully” – wherein the ASA describes themselves as a victim and the sole champion of a righteous cause, and simultaneously plan political moves to eliminate CRNAs

     

    CRNA ADVOCACY ISN’T ABOUT PHYSICIAN “OFFENSE”.  IT’S ABOUT COMMUNITIES.

     Let’s get to the real world.  In 2017, the Arizona Association of Nurse Anesthetists (AZANA) successfully passed pro-CRNA legislation which promoted opportunities for all CRNAs and protected independent practice.  Subsequently, a number of CRNA-only groups were created in the Phoenix market. They have not replaced physicians, but rather responded to increasing demand.

     Who was positively impacted by AZANA’s CRNA advocacy?   The people in my local community.  Let me explain:

    Our all-CRNA group, AzAS, took on a contract in a semi-rural community.  The previous group used an all-MD model, and the MD group did not want The ASA raises an awful lot of political money for not being focused on politics.to continue services due to low revenue. Our group was able to step in and provide the exact same service – and to boot, we also optimized their preoperative screening process to improve patient safety and reduce same-day cancellations, as well as establishing an ultrasound guided regional anesthesia program, with corresponding high levels of satisfaction from patients and surgeons.

     Without that law passed – I’m not sure we would have gotten in the door of the facility.

     Who did that make a difference for?

    1. Patients – who benefitted from the reforms we implemented.

    2. CRNAs – who had new practice opportunities in communities previously unavailable to them.

    3. The facility – who was not likely able to offer an anesthesia subsidy and may have had to close their doors altogether.

    4. The local community and economy – who benefit from having a multi-specialty ASC close to home and from the economic and tax benefits that are derived from that activity.

    When examples like these are extrapolated across the country, it’s clear CRNA advocacy has legitimate benefit, not just for CRNAs, but for patients and communities.  And there’s data on the broader impacts of CRNA advocacy on access and the economy as well.

     Who is not hurt by AZANA’s CRNA advocacy?  Physician anesthesiologists.

    CONCLUSION

     Physicians and CRNAs are both part of a global anesthesiology community. We need to stop having the “CRNA or MD” debate and getting offended – and I fully admit I have offended, and taken offense! But to break the cycle, we must stop thinking “either/or” and start thinking “both/and.“  We must ask ourselves why we cannot have full practice from both professions and let the obvious benefits of safety, choice, flexibility, innovation – and more – grow! That’s another way we stop the 100-year war – to think abundance and not scarcity, to realize society needs the full contribution of both incredible professions, to recognize that both create value for American society, to recognize that neither should try to inhibit the other.  And to begin to design anesthesia teams around patient benefit, rather than industry dogma. Those teams will be MD-only, CRNA-only, and sometimes in a team in a variety of designs.

    “We must stop thinking “either/or” and start thinking “both/and.“  We should just ask ourselves why we can’t have full practice from both professions and let the obvious benefits of safety, choice, flexibility, innovation – and more – grow!

     It’s also important for CRNAs to realize a few things.

    First, that the response of the ASA is hyperbolic and their members won’t be impacted in any significant fashion by CRNA advocacy.  ASA claims of John Garde, CRNA, FAAN. His words still resonate today.“Patients over Politics” are, at best, unaware, and and worst, deceptive.  Second, CRNAs should know that AANA advocacy work is essential – not just for CRNAs, but for communities across the country. I advise that the ASA and their members on Twitter – well, I don’t mean to be patronizing – but take a few deep breaths, because truthfully, they’re going to be just fine. Washington and California are good examples. The world is not in crisis.

    I fully support the AANA’s stance – because it is one of maximum contribution – from CRNAs of course, but it also includes medical doctors, doctors of osteopathy, and dentist anesthesiologists, as experts in the specialty.

     The ASA would do well to realize CRNAs will not ignore the repeated attempts to limit our contributions to patient care. They won’t be tolerated in the future – just like they haven’t been tolerated in the past:

    John Garde, CRNA, FAAN. His words still resonate today.

    “Many activities of the AANA … have been viewed by certain members of the ASA with suspicion and sometimes hostility. Many anesthesiologists, like their colleagues in other medical specialties, believe that the physician is the controller of the health care team…The word ‘control’ is unaccept­able to nurse anesthetists as a group, as it is to other nurses. . . . The goal of the CRNA is for the physician groups to recognize the [CRNA] as a colleague and co-team member, rather than as a physician assistant or extender.”

    — John Garde, CRNA, FAAN, CRNA icon, former AANA President & CEO, in 1977.

    Garde had it right in 1977. And it is the truth now. CRNAs want to be team members and colleagues physicians. And we will work to ensure that we are properly recognized for the degree of expertise we offer, and for the quality and scope of our services we provide. Both groups should stop being offended , stop thinking “either/or” and start thinking #BothAnd.

    That’s Joes take on the ASA’s plan. As a CRNA, what’s your viewpoint or personal experience with “the competition”? Let’s hear your opinion @  tmcnulty@healthcommedia.com.

     

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