I recently returned from a clinical exchange rotation in Taiwan where I spent a month in an academic anesthesiology department.
Taiwan is a single-payer country, with first-world medicine capabilities. Patients pay a very small copay for most things, the government decides what essentials they will cover, and if you want bells and whistles (like a Da Vinci robot) you have to supplement out-of-pocket. While I had a jolly good time helping out with cases and doing a ton of intubations and procedures, I couldn't help but notice the subdued enthusiasm for the field coming from the anesthesiologists. Gas is a rather unpopular specialty in Taiwan. While it's not amongst the least popular specialties there (obgyn and gen surg: "all you need is a pulse"), it's less sought after by med students compared to the US. I asked the attendings why this was the case, they gave two common reasons:
- As an anesthesiologist, your salary is tied to a hospital. Docs who work for hospitals tend to make less than docs who open up outpatient private practice clinics (as a result, family med is more competitive than anesthesia). In Taiwan, salary is a huge driver of med student interest.
- You supervise 4-6 nurse anesthetists at a time. Sometimes this gets up to 8 (!!!) at large, busy academic centers. Interestingly, the attendings seemed proud of their massive case volume, as many had done fellowships in the US 10-20 years ago and felt that 1:1 anesthesia (more prevalent in the US at the time obviously) was too inefficient and boring.
So that's how Taiwan does it. No CRNA independence, just massive supervision ratios. Not surprisingly, anesthesia-related complications and deaths are higher in Taiwan compared to developed western nations. However, the Taiwanese are far less litigious than Americans, as people still respect and trust physicians like in ye olde golden age of American medicine, so lawsuits are uncommon. They tolerate a higher rate of complications in exchange for universal health care.
The nurse anesthetists (NAs) there are less trained than their American counterparts. The vast majority do not intubate or extubate. They could do the occasional A-line if the attending's hands were tied up, but seeing as they were wowed by my med student A-line skills and asked me for advice on placing them... yeah they don't do them often. Their job is to keep vitals stable when the attending is not in the room, and lighten the anesthetic in time for the attending to come back for extubation. If something weird happened intraop, the NAs called the attending back into the room-- sometimes even for minor desats.
Given their limited level of training, the NAs obviously knew their place and would never dream of independence. A few came up to me and asked me wide-eyed why American CRNAs were clamoring for independence. I had to explain that we've trained CRNAs to manage much wider scope of practice than theirs, which led to such high confidence.
So yes, we kind of screwed the pooch in letting CRNAs do so much. We really ought to take back our own intubations and extubations, and stop teaching CRNAs more advanced things like regional. My experience in Taiwan was a little sobering, as I could totally envision how anesthesia in the US might look like Taiwan's if single-payer happens. Lower pay, more supervision. But you know, I can't imagine myself doing anything else than anesthesia. Except pain. Maybe I'll just escape to pain medicine.
