Anesthesiologist versus Anesthetist (Part 1 of 4):

Training, Knowledge, Privileges, Roles

Robert Graboyes, Nina McLain, and Murray Feldstein

A tall, unbreachable wall separates physicians and everyone else—nurses, psychologists, physical therapists, etc. A medical doctor/anesthesiologist (MD) performs similar (sometimes identical) work to that done by a certified registered nurse anesthetist (CRNA). Yet their training, credentials, licensure, privileges, and autonomy can differ sharply. Some states require CRNAs to work under the supervision of a physician, who may or may not have expertise in anesthesia. In any state, a nurse anesthetist who wishes to become an anesthesiologist will essentially have to go back to square one to make that transition—with little credit given to prior training and experience. This physician/nonphysician distinction is deeply engrained in American healthcare. But does the demarcation serve the interests of patients? Or is it merely an artifact of physicians’ 20^th century political power? (Economist Milton Friedman said long ago that the American Medical Association was “the strongest trade union in the United States.”) Here, health economist Bob Graboyes discusses this demarcation with Nina McLain (a CRNA and professor in Mississippi) and Murray Feldstein (a retired urologist who “supervised” CRNAs in Arizona). This is the first of the following four segments:

1. How do MD anesthesiologists differ from CRNAs in terms of training, knowledge, and professional roles?
2. How do collaborative practice agreements (CPAs) work, and what do we mean by “full practice authority” for nurse anesthetists?
3. What would be the present-day logistical hurdles for a nurse anesthetist who wished to transition to the role of physician (medical doctor or doctor of osteopathy)?
4. What institutional arrangements could expedite such transitions, without compromising the quality of care?

While the focus here is on anesthesiology, our discussion is applicable to the physician/nonphysician divide. For simplicity, we will refer here to physicians as “MDs,” while noting that doctors of osteopathy (DOs) serve equally in this role. Before beginning, I’ll note that Nina was my doctoral student at Virginia Commonwealth University and Murray and I co-authored a provocative series of articles arguing that healthcare professions might do well to emulate the manner in which the Federal Aviation Administration certifies pilots. – Bob Graboyes

How do MD anesthesiologists differ from CRNAs in terms of training, knowledge, and professional roles?

BOB: Nina, could you begin the discussion by explaining the institutional arrangements under which CRNAs operate?

NINA: States have differing practice statutes and limit roles certified registered nurse anesthetists (CRNAs) can assume. In many places—for example, rural areas with no anesthesiologists—a CRNA functions as a solo anesthesia provider and has a collaborative practice agreement (CPA) with a physician or dentist; in such a case, the CRNA’s role is no different from that of an MD. In that same state—say in a larger metropolitan area—the CPA may be with a MD anesthesiologist who oversees the CRNA and is available for consultation and emergencies; in this case, the CRNA provides the technical aspects of care to the patient. In yet another area of the same state, the CRNA may have a similar CPA in place with an anesthesiologist, while assuming direction of the patient’s care; the anesthesiologist may push the drugs to put the patient to sleep and, once the patient is asleep and stable, the CRNA assumes responsibility for care, stays in the room, monitors the patient, and handles any issues or hemodynamic changes. These are examples of collaborative, supervision, and medical direction models, respectively. In some states, the nurse anesthetist has “full practice authority” and can operate autonomously, with no need for a CPA with any physician.

As far as skills are concerned, I would consider the training between anesthesiologists and nurse anesthetists to be similar. The National Board of Certification and Recertification of Nurse Anesthesiologists (NBCRNA) sets the requirements for clinical case numbers, clinical hours and experiences, anesthesia techniques, case types, and specific patient statuses the resident must have to sit for the National Certification Exam (NCE). Our program at USM has a synthetic human cadaver (SynDaver) that is more realistic than a “real” cadaver in color and texture. Many medical schools use these as well. We also have virtual reality (Simvana) systems and high-fidelity human patient simulation, along with our static skills models for practice. We use those for things like spinal and epidural training, nerve blocks, and airway management as examples.

Didactically, the physician would likely have full courses in medical school that we do not have in most CRNA programs: for example, cell biology, genetics, histology, embryology, and additional chemistry courses. While we would have the anesthesia-specific content from those types of courses wrapped into our physiology, pathophysiology, and principles courses, we would not likely have full courses on that content in our programs. Anesthesiologists and nurse anesthetists have similar training in the basic sciences, pharmacology, multiple principles courses, health and physical assessment, clinical correlations, seminars, and courses specific to anesthesia. Then, of course, we have our doctoral work on research and methods, epidemiology, population health, policy and politics of healthcare, plus economics and finance of healthcare-type courses. A difference, of course, is that the philosophy of nursing is threaded throughout our program with a nursing focus on patient interaction.

Summing up, our education is from the nursing perspective of care—a holistic approach to healing while building therapeutic relationships, considering the physical and emotional needs as well as any additional or external influences on the patient’s health. The medical perspective is more of a cause-and-effect approach of determining the root cause of symptoms and treating those. At least that is my understanding, simply stated. Historically, at least in my state, we have worked well together to provide the best patient care.

BOB: Murray. A while back, I asked you how the knowledge possessed by an anesthesiologist differs from that possessed by a nurse anesthetist. Could you remind me of what you said?

MURRAY: We need to be conscious that there’s knowledge that we learn from reading and taking courses, and there’s knowledge we acquire from practical experience. All healthcare providers need a fundamental grasp of basic and clinical science, as well as math, before we lay hands on a patient. We can learn some of this in college or professional school. There is additional knowledge we learn during our supervised clinical exposure while studying in professional schools and during postgraduate training. And then there is the additional knowledge and experience that we acquire when we are finally able to work independently. The science of healthcare has changed dramatically over the nearly 60 years I have been part of the medical profession. Much of what I learned is no longer applicable, or was incorrect even when it was taught. So the competence of either a CRNA or an MD anesthesiologist will vary primarily on their practical experience. A lot of this depends upon what opportunities were available to them, and this, as Nina says, will vary from state to state because of political constraints.

It goes without saying that there is a strong individual element to all this. A person who is intelligent, intellectually curious, and compulsive when it comes to patient care will be a better healthcare provider than one who lacks these attributes, no matter which initials follow their name. One’s character is just as important. Honesty, a willingness to work hard and take responsibility, and sufficient humility to realize their own limitations count for a lot.

Taking all of this into account leads me to say that there really is no way to say that all MD anesthesiologists have more knowledge than all nurse anesthetists, or vice versa. You would have to look at each individual’s training, experience, and character.

BOB: In American healthcare, there is this sharp delineation between medical doctors and everyone else involved in care. We speak of “nonphysician providers,” but never of “nonnurse” or “nontherapist” providers. Is this doctors-and-everyone-else model ideal?

NINA: I’ve never thought of the nonnurse concept, hmm. So, a physician is a nonnurse provider. I am a doctor of nurse anesthesia. Personally, I do not let anyone call me “doctor” in the clinical setting, because I feel it is misleading to the patients who are not academically minded. My good friend, Harry Gibson—one of the best anesthesiologists I have ever worked with—is a PhD and MD. Is he a Dr. Dr.?

I think the term “nonphysician” simply came about to try to be inclusive of all us nonphysician providers and to make sure the public knows we are not physicians. Maybe the physicians came up with it, or maybe a great nurse who did not want to be known as a physician did. I do not know. Realistically, I do feel that at one time, it was a doctors-and-everyone-else model, but I feel like this has changed a lot over the last decade as more people and more insurers have begun to fully understand the nonphysician provider’s value. In our state, we have many facilities that practice by the team model, meaning anesthesiologists and CRNAs working together as a team to provide care; the nonphysician terminology is not even an issue. The doctors-and-everyone-else model is far from ideal, to me anyway. When I am the one asleep on the table, I want everyone to get along and functioning well together! I do not want a “them” and “everyone else.” Let’s all just get along and appreciate what each of us brings to the table, which is a lot.

To Murray’s point, all CRNA programs have transitioned to the doctorate level or will have by 2025. It is mandated by our council on accreditation (COA). There is a bit of potpourri in the designations, depending on the school that houses the program. A school of nursing offers a Doctor of Nursing Practice (DNP) degree. A school in allied health professions may offer Doctor of Nurse Anesthesia Practice (DNAP) degree. Of course, there are many different PhDs, so it is kind of a hodgepodge of terminology. But, bottom line, by 2025 all graduating nurse anesthesiology students will be at the academic doctorate level. Most actually are now.

MURRAY: I imagine so. It’s the customary paradigm we have all gotten used to. By the way: Here is an anesthesiologist joke:

Question: What is the definition of an anesthesiologist?

Answer: A half-asleep physician taking care of a half-awake patient.

Here’s some more serious additional thoughts about the doctor/non-doctor paradigm. A lot of physicians get mad when non-MD’s put “Doctor” in front of their name. I have a good friend who is an ear, nose, and throat specialist who gets angry when audiologists use the designation. I think there’s general confusion, especially among physicians, that their “doctor” title is just that. We do not have an academic doctoral degree in the sense that you do, Bob. If anybody should be angry, it should be PhDs. I remind my MD colleagues that an audiologist or psychologist, or any other healthcare worker who is not an MD, is just as entitled as we are to be called by the honorific, “doctor.” And certainly, as Nina points out, advanced practice nurses are more and more frequently becoming doctors of nursing.

BOB: To close this out, I’ll note that some states are making it illegal for anyone other than physicians to refer to themselves as “Doctor So-and-So”—even if they have some sort of doctoral degree, as Nina does. (I have a doctoral degree, too, but I’m not treating any patients.) You can read about it here: https://www.washingtonpost.com/health/2023/08/20/nurse-doctor-scope-medical-titles/, and this would be a worthwhile topic to discuss at some point in the future.

Part 2 of 4

Part 3 of 4

Part 4 of 4

Bob Graboyes is a health economist and Senior Research Affiliate with the Knee Center for the Study of Occupational Regulation. He holds a PhD in economics at Columbia University. He was previously a specialist on Sub-Saharan Africa with Chase Manhattan Bank, and his travels on that continent instilled him with an acute sense of the importance of healthcare and the wildly varying ways that care is delivered.

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Nina McLain is the Nurse Anesthesia Program Administrator and tenured Associate Professor at The University of Southern Mississippi, with a clinical practice in central Mississippi. She has provided anesthesia in several anesthesia models including collaborative agreements with surgeons/physicians as the solo CRNA and in a medical team model of both direction and supervision with MD anesthesiologists. She has been a CRNA for 30 years and a registered nurse for 5 years before that. She served as Vice President of the Mississippi Association of Nurse Anesthetists and is currently on the National Advisory Council for Nurse Education and Practice, which advises the U.S. Secretary of the Health and Human Services. She holds a Ph.D. in Health Related Science from Virginia Commonwealth University.

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Murray Feldstein is a retired urologist. He received his M.D. from the University of Pennsylvania School of Medicine in 1967, did a general (rotating) internship for a year at the University of Oregon, and then served as a general medical officer in the U.S. Army’s 82nd Airborne Division. He took his initial surgical training at the University of New Mexico and then finished his urology training at the University of Arizona—the first resident who graduated from that program. He practiced in Flagstaff, Arizona for 25 years, and also worked at the Tuba City Hospital on the Navajo and Hopi reservations. His partner and he started outreach clinics throughout Coconino, Yavapai, and Navajo counties. Murray briefly retired in 2000, but then was asked to join the Mayo Clinic in Phoenix and became an Assistant Professor until his retirement eight years ago.