"Some animals are more equal than others."---Napoleon, Head PigANIMAL FARM POLITICS
in George Orwell's Animal FarmThe Orwellian Inner Workings of American AnesthesiaFEATURING
Roosters and Ostriches, lying lions,
Dung heaps, mountains and molehills,
Sharks, snakes, pimps and other lowlife,
Worker bees and one mute hound who tells all
THE HENHOUSE
A president of the anesthesiologists' association (A$A) once bragged to Congress that he had personally performed over 300,000 anesthetics. 30 a day for 40 years? Poppycock! Patently ridiculous. Why spout this puffery, this transparent braggadocio? Why is the leadership of the A$A so threatened by the 33,000 CRNAs who are their professional colleagues and their competitors? Why do the doctors protest so much?Anesthesiologists claim that the dramatic rise in anesthesia safety over the last half century is the direct result of larger numbers of doctors trained in anesthesia. Sounds sensible ... at first. But does it really?Remember the classic banty rooster? He crowed and crowed atop his fence post until at last ... up the sun rose in the eastern sky. Then he puffed out his tiny chest and strutted about, declaring, "See there?! I did that! Me! Yeah, me! I made that sun come up!"
That little banty rooster demonstrated the logical fallacy Post hoc, ergo propter hoc, and so do the cockamamie doctors. One thing occurring after another in time does not show causality.
Clearly, space age monitors are one major reason anesthesia is so much safer nowadays, and the doctors know that quite well. But they wish to fool the public. Their claim is typical self-serving cockadoodle bull puckey, runaway rampant hyperbole. I made that sun come up! Yeah, me!
Sadly, hogwash hollow boasts and blatant self-serving exaggeration have become a characteristic behavior pattern of certain anesthesiologists. Their claims do not stand up to examination.
THE DUNG HEAP
When Napoleon the Head Pig in George Orwell's Animal Farm lectured his underlings, he did so from atop the barnyard dung heap, to make himself look bigger, taller, more important. Perhaps it is to impress the politicians, lawmakers and hospital administrators that anesthesiologists construct these mountains of bovine excreta. They crow, "I'm better than a 'anesthesia nurse'; I'm a doctor, so you should take my word for it. Honest!" Then, when confronted with the facts behind their overblown distortions, they stick their heads in the ... sand.
It's scandalous really. Ostriches, roosters, pigs -- beyond the barnyard, the American anesthesia menagerie comprises a veritable zoo. As Marge Simpson says, "This witch hunt is becoming a circus!" And the driving force, the dynamic that animates this menagerie is politics -- politics beyond intramural competition, more like internecine warfare, a bitter battle for the bucks, pure and simple, waged on a distinctly un-level playing field. Why unlevel?
Why, because some animals are more equal than others, of course. If you trust Napoleon the pig's word.
Really now, consider. Do you need a Rolls-Royce to drive to the market? No, a Ford will do. Do we rush to the Mayo Clinic whenever we catch a cold? No, we don't. We certainly don't run to a doctor when we are perfectly HEALTHY! Most patients undergoing anesthesia are quite healthy. For healthy people to routinely pay the high cost of Rolls-Royce anesthesia ... this is waste, waste that borders on fraud. And this fraud is widespread.
Lacking insight to the unique nature of anesthesia, patients, lawmakers, even ostensibly well-informed hospital administrators all too often accept the doctors' unsupported claims and are duped by this one simplistic unfounded presupposition: nurse good, doctor better. Not in anesthesia, not necessarily. Of course we are safer, the doctors claim -- we are more highly educated. Really? Where's the proof that they are any safer providers? Medical decisions should be made based on science, i.e. evidence, not on unfounded presuppositions.
Half the anesthesiologists in America are NOT board certified. Anesthesiologists are sued for negligence at SEVEN times the frequency of CRNAs. That figure would suggest the doctors are in fact LESS safe. Nevertheless, monopolistic control of anesthesia departments is often handed to the doctors. They are given their perch from which to crow and crow and crow.
MILKING THE SYSTEM
Competition is short-circuited by monopolies. Anesthesiologists cost 11 times more than CRNAs to train, and are paid at least 3 or 4 times as much as CRNAs. Anesthesia is anesthesia. Two types of provider, one high standard of care.
Yet, the A$A refuses to even open discussions of peaceful coexistence with the AANA unless nurse anesthetists first acknowledge that anesthesia is solely and exclusively the practice of medicine. You must first kiss my ... ring, then we talk. And they then add, with a wink, "You don't let the stewardess fly the airplane." [An actual honest-to-goodness quote from A$A leadership. You can't make this stuff up.]
Where does one start? So much bovine excrement, so few shovels.
While many valid comparisons can be drawn between anesthesia and aviation, that one above -- 'You don't let the stewardess fly the airplane' -- that ain't one of them. CRNAs do the same job, every bit as well as anesthesiologists, due to the unique nature of our specialty.A little history. At the end of W.W.II there were fewer than 300 board certified anesthesiologists in America. In the 1950s health insurance companies like Blue Cross began to reimburse for anesthesia, leading to -- Eureka! -- a gold rush. Healthy patients! Nurses' work! Big bucks! Doctors flocked to anesthesia, theretofore predominately a nursing specialty since the 1880s.Eventually a new class of entrepreneurial American millionaire arose: the 'supervising' anesthesiologists. Less work, more lucrative and far safer than standing out on a night-time curbstone in the redlight district, soliciting. A 'stable' of CRNAs do the actual patient care; the superfluous so-called 'supervising' doc hogs the lion's share of the bucks.
Some 'supervise' from the golf course. Some, home in bed. They're perfectly comfortable doing so because they know in their hearts, despite their loud public claims to the contrary, that CRNAs are just as capable as themselves clinically, and that patients are quite safe in their absence. Many 'supervise' in the surgery lounge, snoozing with their feet up. (I worked with one who rarely even put on a scrub suit, sometimes for weeks at a stretch, so unneeded was he. Another 'supervised' from out of state.)
Why is so-called 'supervision' so popular among anesthesiologists? Unearned income of course. The drone collects, the worker bees work. It's fraud all over again. And again, widespread.
So, what is the anesthesiologists' place? (Not just hidden in the lounge with the donuts, coffee and CNBC on TV.) As perioperative specialists, anesthesiologists can contribute expert advice in the management of the rare complicated patient -- perhaps one in a thousand cases. I'm reminded of a true life encounter between high level representatives of the A$A, the AANA, and a US Senator: [An actual encounter, paraphrased from first person reports.]
"What are you there for?" the Senator asked the doc. "The CRNAs appear to do all the work in anesthesia."
After a pause she said, "Well, I'm there for when the shit hits the fan." [Her actual exact words, verbatim. You cannot make this stuff up.]
... Taken aback, the Senator asked her to elaborate.
The doctor opined that when a problem arises, an anesthesiologist can help a nurse anesthetist to rescue the patient, whether it be managing a difficult airway, whatever.
"How often does this come up?" the Senator asked.
The doctor was vague.
The Senator persisted. "Every day?"
"Oh, no. Modern anesthesia is quite safe. Mortality's only one in a quarter million."
"Well? Every week? Once a month?"
The doctor admitted that at her own institution such a situation was likely to occur perhaps once every six months.
"So you are telling me," the incredulous Senator concluded, "that we pay you three times as much as a CRNA so you can hang around and 'be available' twice a year? Incredible!"
MUTE HOUND SPEAKS VOLUMES
If doctors were in fact overall superior anesthetists, as they claim, would not someone over the last one hundred and twenty years have noticed and documented that fact? Could it not be easily proven?
I suggest the British medical system holds the key to refuting the American anesthesiologists' characteristically overblown claims. Bear with me. The proof itself is the very lack of evidence.
In The Hound of the Baskervilles Sir Arthur Conan Doyle (himself a Scottish physician) had Sherlock Holmes catch the murderer because the man's own dog did not bark, at the supposed intruder who committed the murder. No barking, therefore the hound knew the killer, and his silence indicted his master. Elementary, my dear Watson.
Now ... Britain uses only physician anesthesia providers. Half the hospitals in America use only nurse anesthetists. So if the A$A argument of superiority held water, British anesthesia should be clearly and demonstrably better than America's.No. Nothing of the sort. There is no significant difference between American and British morbidity and mortality statistics in anesthesia. Anesthesia is extremely safe, equally so in both countries..Does such a difference exist?
Anesthesiologists do not by mere virtue of any scholastic degree do safer anesthesia than CRNAs. That ole banty rooster never once made the sun come up. Hollow boasts, all that hogwash.Anesthesia is Anesthesia Two classes of provider in America, one uniformly high standard of care. CRNA or anesthesiologist, rich suburbs or poor boondocks, quality of care is high nationwide. No scientific study of anesthesia outcome has ever distinguished a significant difference in quality between the two types of providers.
Still, the doctors' lies and distortions and poppycock go on.
And meanwhile, down in the depths of the American anesthesia workplace, hidden behind O.R. doors those true beasts of burden, the worker bees the CRNAs, we endure, doing the best job possible for our patients. And we steadfastly fight the political battles one must fight, when you make your living by swimming with sharks.
Some barnyard!
--- WJ
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