Expert: Ronald Levy, M.D. - 3/4/2010

Question
I just returned from an abortive attempt at surgery; I was told in the preop interview that an anesthesiologist would be performing my anesthesia, but just before surgery I was informed that a CRNA would be doing the anesthesia and that an anesthesiologist was supposed to be available supervising multiple anesthesia cases.  Needless to say, I cancelled the surgery.   I do not believe that a CRNA is in any way equal to an anesthesiologist; the CRNA who was to do my case said that she could do anything that an anesthesiologist can and that she doesn't even have to have one available.  I checked with the State Board and she's technically right; I just don't think that this is a safe practice.  The anesthesiologist said that most places have him supervising multiple CRNA's; sometimes they don't even have an anesthesiologist available.  I have 2 questions:  if CRNA's are "equal" to anesthesiologists, then why do we have anesthesiologists?  Secondly:  what happens when there are simultaneous emergencies (say when an anesthsiologist is supervising several CRNA's at the same time)?  Certianly, the anesthesiologist can't attend to 2 emergencies at the same time...I really appreciate your input; my surgeon is fuming that the surgery was cancelled and the anesthesiologist would only say that "that's the way it is, the CRNA's have a powerful lobby".  Thanks.

Answer
CRNAs do not have independent practice privileges in this country but they are allowed to administer anesthetics under the supervision of an MD. I don't know what state you are from but the rules generally state that a CRNA must be supervised by a physician (preferrably an anesthesiologist). What does this mean? In some locations where there are no anesthesiologists (MDA), a CRNA can perform the anesthetic and the surgeon (technically) is supervising. There is a big difference between MDAs and CRNAs and that has to do with education. While both can administer an anesthetic, the MDA is generally better able to manage the complex cases and the emergencies than the CRNA. That being said, many CRNAs are technically very qualified to function semiautonomously. As your anesthesiologist told you, it is not uncommon for one anesthesiologist to supervise 4 CRNA. While not ideal to manage so many, this is a practical matter. Imagine the alternative whereby there aren't enough MDAs at your facility so they would not be able to do as many surgeries a day and they would back up. It's not a perfect world but from the hospital's perspective, CRNAs are cheaper than MDAs so they would prefer to hire more of them than MDAs. Regarding emergencies, it is highly unlikely for there to be 2 emergencies simultaneously but even if there were, assuming there is more than 1 MDA at your hospital, the other MDA(s) would be available to assist with the additional emergencies.

So what can you do. I will start out by saying that I don't have a problem with a CRNA performing an anesthetic. Clearly it may depend on your underlying health and what type of procedure you are having. Certainly you have the right to have an MD anesthesiologist only perform your anesthesia but you cannot force the MDA at that hospital to do that. If the hospital where your surgeon works does not offer that service, you may have to change surgeons or hospitals or see if you can arrange in advance for an MDA. Most places have 1 or 2 MDAs that do their own cases. Your other option might be to go to a teaching hospital where they have residents. While residents are in training, they are MDs and they are more closely supervised than CRNAs.

I hope this answers your questions,

Ronald Levy, MD
Professor of Anesthesiology
UTMB-Galveston