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’ 20th 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 second of the following four segments:
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 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 collaborative practice agreements (CPAs) work, and what do we mean by “full practice authority” for nurse anesthetists?
BOB: Nina, could you explain the nature of Mississippi’s requirement that you establish a CPA with a medical doctor? What is involved in the establishment and maintenance of such an agreement, and what is the real impact on your practice? Does a CPA help you, hurt you, or neither? And how does it affect the patient?
NINA: Sure. A CPA in our state is called the collaborative agreement and is mandated by our state licensing agency, the Mississippi Board of Nursing (MSBON). In Mississippi, CRNAs fall under the advanced practice registered nurse (APRN) categorization. In our state, APRNs are required to have a CPA with a physician or dentist who has an unrestricted license to practice. This is mandated in the Mississippi Nursing Practice Law, and officially called a “collaborative/consultative relationship with a dentist or physician.”
As far as what is involved in a CPA, prior to working at each specific facility, the CRNA must have a physician or dentist who is amenable to collaboration and complete the online process of adding them to their practice site on the MSBON Nursing Gateway website. We pay a fee of $25 to add a new collaborator and a $25 fee to add a new clinical site. Once the addition is approved, the CRNA gets an email from the MSBON and the CRNA can then practice. The CRNA or facility keeps a copy of the CPA protocol on file at the facility. A quality-improvement plan with monitoring has to be carried out and reviewed by the collaborating physician or dentist on a regular basis. Usually, this will occur in the form of chart reviews but other methods are not excluded. For CPA maintenance, most that I am aware of, renew automatically unless ended by one of the parties.
You asked “what is the real impact” on our practice. Well, big in that we cannot practice legally without the CPA, but realistically, the existence itself does not alter what we do or how we practice. We are held to the same standards of care that a physician anesthesiologist is whether we are practicing in the same room or alone with a collaborative surgeon or dentist in an operating suite or dental office. If one were in court, the standard of care is the same whether you are a CRNA or an MD.
There is a lot of disagreement among providers as to if the CPA helps or hurts. I think that is the tale of two views. Some feel the CPA is totally unnecessary and for good reason. Some feel it is absolutely necessary, and, honestly, they have some good thoughts too. The reality is much what Murray already alluded to—it depends on the people.
I personally don’t think a CPA is useful in any model of anesthesia care, and I have enjoyed working in them all. The CPA has never been an issue for me. I do have it in place to collaborate and coordinate patient care with my physicians, surgeons, endoscopists, or radiologists. (However, it does not change my plan of care or delivery of anesthesia to the patient.) I would add dentists, but I have not worked with them in that capacity. I would collaborate with them when necessary whether I had a CPA or not.
Collaboration does not mean “dictate or direct care,” and I think people get confused on that issue. “Communicate” is a better word, in my opinion. CRNAs are well trained to develop pre-anesthetic assessment and evaluation; develop management plans; provide complete peri-anesthetic care, including induction, maintenance, and emergence of anesthesia; perform the tasks needed to care for the patient; and handle any situation that arises, whether crisis or routine. Essentially, that is what is in the CPA. I’m required to have it, so I do. If you removed it tomorrow, my personal anesthesia practice would not change in the care I give a single bit. There are many CRNAs whose practices are limited because of the model in the facility where they practice—but it is not by the CPA itself.
However, I guess to answer your question, a CPA does hurt many CRNAs in that their agreement may be with a collaborator who does not want them practicing to their full scope, as in some medical direction models. However, in rural America and a good portion of Mississippi, where there are no anesthesiologists, collaboration with a physician (or dentist) is a required formality; CRNAs can practice to their full scope, because many of the skills or certifications they have are not possessed by the physicians with whom they collaborate. In many supervisory practice models, CRNAs are able to practice to their full scope, as their supervising anesthesiologists understand the value of that team-practice model. Fortunately, I have the best of both worlds in that I work with collaborative surgeons/physicians who are very skilled and brilliant. I have known CRNAs, anesthesiologists, surgeons, and physicians I respect as much as you, and I would go down fighting for them. A couple—well, not so much. So, as both Murray and I mentioned, it just comes down to the people, and, I guess, the model of practice.
BOB: And Murray, could you please recount your experience managing a group of nurse anesthetists? How did that come about? What was involved in supervising these NAs? And do you think the arrangement was beneficial to you, to the NAs, or to the patients?
MURRAY: I did not “manage” a group of nurse anesthetists in any meaningful sense. I collaborated with them as colleagues. Nominally, and only for legal purposes, I “supervised” them during surgery. There was no anesthesiologist within 150 miles of our hospital. Anesthesiologists tended to work in large communities, and at the time, Flagstaff was only 32,000 souls. Specialists were just beginning to move in, and the town was growing. The three nurse anesthetists were quite experienced doing the kinds of procedures done in community hospitals. I wouldn’t have been able to operate without them. They were excellent. I had administered anesthesia under supervision as a medical student and as an intern. There were no anesthesiologists at the Veterans Hospital in Tucson, so I worked with nurse anesthetists there when I was a resident at the University of Arizona. The fact that there were no anesthesiologists in Flagstaff didn’t bother me.
So, let’s talk about this idea that I “supervised” the nurse anesthetists in Flagstaff. That was a convenient fiction, a necessary lie that had to be told to satisfy Arizona’s medical practice act, because at the time, it was illegal for nurse practitioners to act independently. But the three nurse practitioners I worked with all knew a helluva lot more than I did about their work. There’s no way I’m going to stop what I’m doing if I get into trouble removing a big kidney cancer and tell the nurse anesthetist what he or she has to do. They all knew what had to be done. We just dotted some i’s and crossed some t’s with paperwork, and it became legal. That’s what was done around the country in every hospital like ours. Thankfully Arizona is one of the more enlightened states, and, after a protracted turf war in the state legislature, nurse anesthetists can now practice independently, and everyone can stop lying.
As an aside: The three nurse anesthetists have all retired. Flagstaff now has a large staff of well-trained anesthesiologists, and I believe they employ some anesthetists. But there was a brief time in the late 1970s when a newly trained anesthesiologist came into town and insisted that he was going to run the anesthesia services and make the three experienced anesthetists into employees. But it turned out he was not nearly as skilled as they were, so the surgeons refused to let them put their patients to sleep. And he left town a year later.
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.
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.
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.