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 fourth 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 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
What institutional arrangements could expedite such transitions, without compromising the quality of care?
BOB: Murray, you and I have written about conjectural licensing regimes in which there would be more of a spectrum of certifications, rather than the unbreachable walls that separate medicine from nursing, therapy, and other healthcare professions. As an alternative licensing model, you and I looked to the “stackable” certifications that the Federal Aviation Administration uses for pilots and other flight personnel. If a pilot certified for single-engine propellor-driven planes wishes to fly Lear jets, he or she has to acquire new skills and certifications, but does not have to go back to Cessna school– the way Nina would have to go back to med school to become a doctor. Let’s explore the advantages (and disadvantages) of such an alternative licensing system.
MURRAY: I believe there are considerable advantages to the kind of stackable certifications we discussed in our article. And by the way, I was, a long time ago, a private pilot. So I’m familiar with the differences between the way the two professions are certified or licensed. If we were to adopt the theoretical system we envisioned in our paper there would be a huge impact on the training and specialization of all healthcare providers. Many opportunities would open for healthcare providers that are currently unavailable.
Take the example of the CRNA with a moderate amount of experience doing only elective procedures who decides to work now with a transplant team. Under the current regime, only MD anesthesiologists can do this type of work unsupervised (at least in some states). The nurse cannot just get trained up to the new task without going through some period of supervised experience. But only MDs are allowed into the post-graduate programs (residencies) that provide that kind of training. So, the nurse has to get the MD degree in order to have the opportunity to get the training. Just as Nina pointed out, this means applying and getting accepted to a medical school which might require going back to take come college courses. Then there would be the four years of medical school to get the MD degree—essentially repeating two whole years of taking the anatomy, biochemistry, pharmacology, and physiology that the nurse already knows. Following this basic clinical training, the CRNA will have to spend additional years learning things that she will never need in her anesthesia job—things like obstetrics, psychiatry, well-baby pediatrics, etc. After graduating medical school and being accepted into an anesthesia residency (assuming she gets into such a residency), the nurse will have to repeat another 2-3 years of general anesthesia instruction he or she has already had before, until finally–finally–getting a 2-year fellowship in the subspecialty of open cardiac surgery including heart transplantation. If my math is correct we’re looking at an additional 8-9 years of training.
In the system we discussed in our paper, a post-graduate training program for open heart surgery might be willing to accept applicants who are not MDs, but who have recognized certified skills and training as acceptable qualifications. The system we envisioned recognizes competence and experience rather than just an MD degree (which is only a proxy for competence). Presumably, this “stackable” approach would significantly cut the length of time for transitioning from CRNA to MD (or some equivalent career move).
NINA: I knew I liked Murray. I used to fly too, but only a Cessna 182. I had full plans to continue on and get my instrument rating and certification to fly my hubby’s (now ex-but still great friends) Citation. But, I got pregnant and the baby boy became the focus, and flying fell to the wayside. So, I am familiar with the FAA certifications as well.
I think with the AD in nursing, then BS to MS to PhD route that I took, and my extra science courses, I could maybe do it in 6-8 years if all my coursework transferred, but now it is too late because that has been … a minute or 30 years. It would probably take longer for those who took the nursing bachelor’s straight to doctorate in nursing path, because they would have fewer science and math courses.
BOB: I think a more flexible system–something resembling the FAA’s licensing system–could have strong, positive effects on the availability of healthcare resources in underserved areas. (Rural areas, inner cities, etc.) What do you think?
NINA: Absolutely. As a resident in a rural-underserved county, and state in most cases, I do not live where I teach. I totally agree. In the context you are speaking of, I honestly think in a way, nursing has already had something close to this although it is not recognized as such. We have Licensed Practical Nurses (LPNs), 2-year associate degree RNs, then bachelor’s prepared RNs, master’s level nurses, and APRNs (both doctoral and masters prepared). There has been a big push to get away from the LPNs and 2-year associate nurses over the last decade in many states. I could not really buy into it. Ages ago, around this area, the best nurses came from a hospital diploma program, really. They were great. Some of the best nurses I have worked with, and still do, are LPNs and 2-year associate-degree nurses. Historically, their roles were more technical and, in my personal opinion, that experience, combined with the patient compassion they bring to the table, is a huge thing missing in current healthcare.
Then COVID hits. Nursing shortage, crisis galore. Sure would be nice to have some people who know how do nursing care at the patient level that does not require a higher degree, right? Not everyone needs to have a “professional” degree designation. Remember, these are my personal opinions only.
I believe we still have a place for the LPNs and 2-year RNs, who by the way, are often just as good at critical thinking (and in code situations, too) as the bachelor’s nurses and physicians. I know, I know people think I am not supposed to feel that way for a bunch of reasons, but maybe that should be revisited. Both the LPN and associate nursing routes are also great pathways to get the high school student whose GPA will not let them get into a competitive bachelor’s program into an entry level nursing position earning money. An LPN can “upgrade” by going back to take courses for their RN degree, then do a bridge course to their bachelor’s. If they choose to go on, they can earn their master’s or doctorate and might even be a CRNA or family nurse practitioner one day. Maybe even a dean of a college of nursing. If one chose that path—LPN to doctorate level—that would take about 8-9 years total. Similar to bachelor’s and medical school, right? Help the underserved become those who serve the underserved. Neat concept, economically feasible in my opinion.
I suppose we could reinvent the wheel and repackage it into a certification instead of license model, but it would make more sense to me to take what we have and streamline what would be taught at each of the levels a little better and roll with it. I will say, we have new standards and essentials from the American Association of Colleges of Nursing (AACN) for bachelor’s to doctorate levels and here is where I go off script and may get daggers thrown at me (but you know me Dr. Graboyes and Dean Story if you are reading this). We could add in the 2-year associates and the LPN competency levels and “voila!” There are your stackable certifications doc, for nursing. But, I am a dreamer, and hate to be told that something can’t be done.
As far as I know, there is no similar pathway for physicians. There may be, I would have to defer to Murray on that one.
MURRAY: I still opt to go to a stackable certification program rather than “streamlining” what we have now, but I advocate a “sneaky” way to do it. What we have now is a state monopoly in licensing regimes, and political considerations are often the most important factor in deciding how the monopoly operates: which big dog owns the territory as it were. Why else would 50 different states have 50 different scope of practice laws for nurses, physical therapists, etc? The answer, of course, is that in one state, the nurses have more political pull, and in others, doctors are the victors in defending their turf.
What Bob and I proposed in our paper is letting the states have the final say in which accrediting organizations are good enough to be accepted on their accreditation registry, but then letting those organizations define what it takes to be competent. There is going to be overlap in some areas between professions and even within professions. And those are the areas where turf wars erupt, and politicians, who often know nothing about medicine, get to decide who gets to do what. In the system we propose, those are the pressure points where competition gets to exert its beneficial effects. It will lead to the programs becoming both more equitable and more efficient in who is acceptable for training, what is taught, and how long it takes to be trained for any given competency. And while politics is always going to be a factor, the states can outsource its deciding what accreditation boards are acceptable by relying on the standards established by the American Board of Education, among other such meta-accreditation organizations.
Nina, think of the many different ways the entry pilot, flying by visual flight rules in a single engine plane, can progress to become an airline pilot, or anything in between, such as a commercial pilot flying customers with an instrument rating in a single engine seaplane to an isolated lake in Alaska. (I’d love to be fishing in one of them right now!)
Stripping the state medical boards of their respective monopolies would incentivize medical training institutions at all levels to reconsider their requirements and their curriculum. Graduate nurses, psychologists, physical therapists, optometrists, pharmacists–and even MD’s–have accumulated skills that could allow them to choose from a menu of post-graduate programs that could diversify their skill sets and allow them to adapt to whatever are the particular needs of their practice setting.
BOB: To throw just one more item into the mix—a big item—medical schools, other healthcare schools, licensing boards, and other players are rapidly imposing ideological litmus tests on their students and practitioners. I think this will soon constitute a real crisis, if it doesn’t already. I think it will have negative impacts on patient care. Establishing parallel modes of education and licensure (or certification) are just about the only way that I can think of to defuse this situation.
A big thanks to both of you for this excellent conversation.
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.