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Memphis Business Journal
From the October 24, 2005 print edition
Anesthesiologists may be losing foothold against nurse anesthetists
Scott Shepard
Doc Holliday, like dentists and surgeons for 5,000 years, controlled patients with a simple anesthetic: whiskey. Archaeological records indicate that as far back as the Aztecs and Sumerians, alcohol was part of surgical medicine.
Even though ether was invented in 13th century Spain, it remained a party drug for 500 years until 1842, when Crawford Long used the laughing gas to put out a patient long enough to remove two neck tumors, working in Jefferson, Ga.
Since then, any number of newer chemicals have been developed for more reliable, predictable sedation. And that's sparked one of the harshest turf battles in medicine.
The question is: have anesthesiologists advanced their science so far that they are no longer needed? Can it now be turned over to an army of Certified Registered Nurse Anesthetists, who will work for about a quarter the salary?
"It's a political turf battle, and it's all about money," says CRNA Brent Earwood, who practices with West Tennessee Anesthesia in Jackson, Tenn. "State law has nothing that requires physician supervision of CRNAs; legally, I could go into any hospital and practice independently under the surgeon's license."
With nine nurse anesthetists covering 14 rural hospitals, West Tennessee Anesthesia is the nation's largest CRNA practice. Nearly 1,500 mostly-rural hospitals are served exclusively by nurse anesthetists. Since only a physician can prescribe a drug, the nurses must practice under the auspices of the surgeon. In normal life the surgeon has plenty to do with cutting and sewing and leaves the anesthesia decisions to the nurse.
Physician anesthesiologists tend to gather in large urban areas, but even then most the anesthesia is administered by a CRNA. Medicare rules allow an anesthesiologist to supervise up to four nurse anesthetists at a time.
Most anesthesiologists try to be in the operating room as the patient goes under, and when they awaken. They spend their time moving back and forth between operating rooms monitoring patients.
"There's more to anesthesia than putting someone to sleep; there's a medical aspect," says anesthesiologist Gary Kimzey with Medical Anesthesia Group. "An orthopedic surgeon is great at fixing a broken hip, but he's focussed on the hip and not thinking about the other medical aspects."
His group has 35 physicians and 36 CRNAs covering Methodist hospitals, St. Jude Children's Research Hospital and several surgery centers.
Kimzey conducts a medical history on his patients, and works with hospitalist physicians to manage any underlying conditions, such as congestive heart failure or hypertension. Then he plans the best anesthesia regimen for that patient.
It's that work that makes the nurse anesthetist effective, he says. As the only other doctor in the room, he's also prepared to step in and assist the surgeon if something goes awry.
"It used to be that one-in-50,000 people would have a problem in surgery, and now it's one-in-500,000," Kimzey says. "Part of that difference is the research and developments by anesthesiologists."
The idea that anesthesiologists aren't needed was bolstered in the Southeast 18 months ago when the University of Tennessee Health Science Center learned its residency program accreditation was under probation -- one of several steps reflecting a lack of enrollment. Meanwhile, the CRNA program at the UT College of Nursing continues to turn out nurse anesthetists. Earwood's group could hire another 10 tomorrow, the demand is so high.
The situation is more simple, Kimzey believes. Anesthesiologists at a medical university expect to do further research into better drugs and monitoring devices. Starved for cash and burdened with TennCare reimbursement rates, doctors at UT are expected to turn patients and generate revenue.
It's not an environment good for recruiting.
Earwood acknowledges the research contribution of anesthesiologists, and has seen dramatic changes since he began practicing in 1991. He also notes that anesthesia is the only medical field that doesn't diagnose and treat, but only provides ongoing care, which is what nurses do best.
"Anesthesia is 50 times safer than it was just 20 years ago," Earwood says. "The question is when do you treat a patient in a rural or an urban hospital. He may need more interventional care than we could provide in Humboldt after the surgery. The way to keep out of trouble is to know your limits."
From the October 24, 2005 print edition
Anesthesiologists may be losing foothold against nurse anesthetists
Scott Shepard
Doc Holliday, like dentists and surgeons for 5,000 years, controlled patients with a simple anesthetic: whiskey. Archaeological records indicate that as far back as the Aztecs and Sumerians, alcohol was part of surgical medicine.
Even though ether was invented in 13th century Spain, it remained a party drug for 500 years until 1842, when Crawford Long used the laughing gas to put out a patient long enough to remove two neck tumors, working in Jefferson, Ga.
Since then, any number of newer chemicals have been developed for more reliable, predictable sedation. And that's sparked one of the harshest turf battles in medicine.
The question is: have anesthesiologists advanced their science so far that they are no longer needed? Can it now be turned over to an army of Certified Registered Nurse Anesthetists, who will work for about a quarter the salary?
"It's a political turf battle, and it's all about money," says CRNA Brent Earwood, who practices with West Tennessee Anesthesia in Jackson, Tenn. "State law has nothing that requires physician supervision of CRNAs; legally, I could go into any hospital and practice independently under the surgeon's license."
With nine nurse anesthetists covering 14 rural hospitals, West Tennessee Anesthesia is the nation's largest CRNA practice. Nearly 1,500 mostly-rural hospitals are served exclusively by nurse anesthetists. Since only a physician can prescribe a drug, the nurses must practice under the auspices of the surgeon. In normal life the surgeon has plenty to do with cutting and sewing and leaves the anesthesia decisions to the nurse.
Physician anesthesiologists tend to gather in large urban areas, but even then most the anesthesia is administered by a CRNA. Medicare rules allow an anesthesiologist to supervise up to four nurse anesthetists at a time.
Most anesthesiologists try to be in the operating room as the patient goes under, and when they awaken. They spend their time moving back and forth between operating rooms monitoring patients.
"There's more to anesthesia than putting someone to sleep; there's a medical aspect," says anesthesiologist Gary Kimzey with Medical Anesthesia Group. "An orthopedic surgeon is great at fixing a broken hip, but he's focussed on the hip and not thinking about the other medical aspects."
His group has 35 physicians and 36 CRNAs covering Methodist hospitals, St. Jude Children's Research Hospital and several surgery centers.
Kimzey conducts a medical history on his patients, and works with hospitalist physicians to manage any underlying conditions, such as congestive heart failure or hypertension. Then he plans the best anesthesia regimen for that patient.
It's that work that makes the nurse anesthetist effective, he says. As the only other doctor in the room, he's also prepared to step in and assist the surgeon if something goes awry.
"It used to be that one-in-50,000 people would have a problem in surgery, and now it's one-in-500,000," Kimzey says. "Part of that difference is the research and developments by anesthesiologists."
The idea that anesthesiologists aren't needed was bolstered in the Southeast 18 months ago when the University of Tennessee Health Science Center learned its residency program accreditation was under probation -- one of several steps reflecting a lack of enrollment. Meanwhile, the CRNA program at the UT College of Nursing continues to turn out nurse anesthetists. Earwood's group could hire another 10 tomorrow, the demand is so high.
The situation is more simple, Kimzey believes. Anesthesiologists at a medical university expect to do further research into better drugs and monitoring devices. Starved for cash and burdened with TennCare reimbursement rates, doctors at UT are expected to turn patients and generate revenue.
It's not an environment good for recruiting.
Earwood acknowledges the research contribution of anesthesiologists, and has seen dramatic changes since he began practicing in 1991. He also notes that anesthesia is the only medical field that doesn't diagnose and treat, but only provides ongoing care, which is what nurses do best.
"Anesthesia is 50 times safer than it was just 20 years ago," Earwood says. "The question is when do you treat a patient in a rural or an urban hospital. He may need more interventional care than we could provide in Humboldt after the surgery. The way to keep out of trouble is to know your limits."
