Hiring a CRNA: What to Expect

In the world of medicine, Doctor is an esteemed title to achieve. Yet, there are some situations with ongoing debates on whether a physician is the best candidate for a particular position of care.

This is true when it comes to anesthetics. If you have open heart surgery do you want your life managed by a nurse or a doctor?

Many hospitals and practices would rather hire a certified registered nurse anesthetist (CRNA) vs. an anesthesiologist. Other hospitals would consider an anesthesiologist a necessity to become a qualified anesthesia provider.

Why is this so? What benefits come with hiring a CRNA as opposed to a licensed anesthesiologist?

This article will look into the ins and outs of both roles and focus on the value a CRNA could bring to your anesthesia care department.

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CRNA vs. Anesthesiologist: Education

One of the most significant differences between a CRNA and an anesthesiologist is the type and amount of education they must complete to earn their title.

Anesthesiologist Education

An anesthesiologist spends many more years in college and training than a CRNA does.

First, they must attend college, pursuing a bachelor’s degree in science. This is their pre-med education and is considered nonmedical training.

After completing those four years, anesthesiologists must spend an additional four years attending medical school.

After graduation from medical school, a doctor wanting to become an anesthesiologist would then complete a four-year anesthesia residency. This is where the in-depth training takes place.

Most anesthesiologists take advantage of an optional fellowship in anesthesiology to bolster their experience.

CRNA Education

The education of a CRNA is much shorter in comparison to an anesthesiologist, although their educational requirements have increased in recent years.

The first step to becoming a certified registered nurse anesthetist is to graduate from a nursing program.

While many nurses get a BSN, most CRNAs get a master’s degree. This makes them an official Advanced Practice Registered Nurse (APRN). However, you can become a CRNA after graduating from any nursing program ranging from one to four years.

They must then spend a year learning critical care. This experience prepares a CRNA to handle emergency anesthesiology situations. However, in an emergency, the anesthesiologist is usually the best suited professional.

After critical care, CRNAs complete three and a half years of an anesthesia program with an optional year fellowship.

When reviewing a side-to-side comparison of education, anesthesiologists spend much more time in university cumulatively. However, a CRNA would actually complete a half year more in medical training than the doctor.

It’s important not to forget that a nursing program will teach a whole different educational path of medicine than that of a doctor of medicine program.

While nurses learn to follow a set of strict protocols, doctors are trained to look at the situation and use their in-depth medical training to make the best decision.

According to the Council on Accreditation, all anesthesiologist healthcare professionals will require a doctoral degree, or DNP, by the year 2025 to complete a CRNA program.

Related: The Full Breakdown to Medical School Student Loans.

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CRNA vs. Anesthesiologist: Responsibilities

Another area in which a CRNA will often differ from an anesthesiologist is the responsibilities that come with their title.

Understandably, an anesthesiologist usually has more responsibilities. Yet, there may be times when a CRNA is all that is available and will take over the anesthesiologist’s duties.

There are certain times CRNAs would not be qualified, but in most “bread and butter” cases they most definitely can and should be used.

Anesthesiologist Responsibilities

An anesthesiologist must meet specific qualifications to practice. They must be board certified and licensed in any state that they wish to practice in.

Anesthesiologists must also complete a MOCA certification every ten years. This certification is simply a refresher, or maintenance, of the certification they passed in the beginning.

This certification will ensure that the doctor:

• Stays up to date with the newest practices
• Is still licensed and remains in good standing
• Is consistently improving in their practice

The clinical responsibilities of an anesthesiologist are to lead the anesthesia care team and oversee their work.

Anesthesia Types

There are a variety of anesthesia types that must be learned and practiced by an anesthesiologist:

• General Anesthesia – anesthesia that puts the patient into complete unconsciousness used during major surgeries.
• Monitored Anesthesia – can cause a variety of levels of sedation depending on the procedure being done.
• Regional Anesthesia – a form of anesthesia that is used for pain management of a larger area of the body. A patient is fully conscious during this type of anesthesia.
• Local Anesthesia – similar to regional anesthesia but for a much smaller area of the body.

Anesthesiologists often spend so much time overseeing that they have little hands-on tasks in the operating room, but this completely depends on the type of practice and the cases that are at hand.

While a CRNA could handle many operations to cut down on the expense of the procedure, there is a clear line in the responsibilities of an anesthesiologist that cannot be taken on by a CRNA as this is out of their scope of training.

Classification System

There is a classification system that predicts the risk and complexity of the procedures based on a variety of factors that only an anesthesiologist can determine.

This system is called the ASA Physical Status Classification.

The ASA system takes into consideration the state of the patient as well as the complexity of the procedure. This chart breaks down the levels of ASA within the scope of adult anesthesia, pediatric anesthesia, and obstetric anesthesia.

While an anesthesiologist can complete every level on this chart, a CRNA cannot. To best utilize your anesthesiologist team, a healthcare practice would set up a system that allows each member to fill their roles.

Following this classification system, an anesthesiologist should be responsible for the more complex procedures that fall into the ASA levels 4, 5, and 6. There may be times when an anesthesiologist should complete a procedure if it falls into ASA levels 1, 2, and 3.

CRNA Responsibilities

A CRNA must also be board certified and state licensed. But, the recertification of a CRNA is not every ten, but every four years. They must also pass the Continued Professional Certification exam every eight years.

A certified registered nurse anesthetist’s clinical responsibilities could include:

• assessment and evaluation
• administering of pre-anesthetic drugs
• developing an anesthesia care plan
• performing airway management

And much more.

While an anesthesiologist could also complete these responsibilities, it makes much more sense to allow the CRNAs to handle these to increase the profit margin of the practice.

Within the ASA Physical Status Classification, these duties fall within the ASA 1, 2, and sometimes 3.

The American Association of Nurse Anesthetists gives a detailed description of what this position entails and what types of responsibilities a CRNA could include.

They also provide information on the possibilities of advanced pain management duties as well as non-clinical responsibilities of a CRNA.

In 14 states, CRNAs require no supervision of an anesthesiologist, although this is a widely debated issue.

A practice that employs both anesthesiologists and CRNAs should take advantage of the cost-effectiveness of allowing the CRNAs to take some of the workload off the anesthesiologist and increase the productivity of the entire anesthesia care team.

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CRNA vs. Anesthesiologist: Quality of Care

The biggest concern to a healthcare system is how these two medical professionals compare when it comes to the quality of patient care they offer.

There are many different areas of anesthetics that may need addressing:

• Cardiothoracic Anesthesiology
• Critical Care Anesthesiology
• Neurosurgical Anesthesiology
• Obstetric Anesthesiology
• Pain Medicine
• Pediatric Anesthesiology

Both CRNAs and anesthesiologists can qualify to work in these areas. However, CRNAs may need to undergo extra training in order to gain these clinical privileges. Anesthesiologists often specialize in one of these areas.

When utilized in the correct manner, well-trained CRNAs and anesthesiologists should be providing the best possible quality of care for all patients.

The quality of care comes into question when health professionals begin to take on responsibilities out of their abilities or are overwhelmed by too many responsibilities due to the lack of help from health care professionals that offer a supporting role.

This is why hiring a CRNA to support your anesthesiologist can greatly improve your practice’s anesthetic quality of care.

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The Big Debate Issue

Anesthesiologists claim to enter the workforce with five times the clinical experience than CRNAs.

However, The AANA claims that CRNAs log 9,369 hours between their nurse anesthesia educational program and their critical care program.

Since anesthesiologists claim to earn 12,000 hours of clinical training, these numbers don’t add up.

This contradictory data is a result of two opposing titles vying for their part in the anesthetic industry.

While CRNAs claim that the data anesthesiologists present is very outdated, anesthesiologists argue that even the title nurse anesthesiologist should be done away with.

The Cochrane Collaboration, an evidence-based medical collaboration, completed a review of the years of varying studies already done on this topic.

Even this review, which aimed at putting a definitive answer on the subject, turned up some conflicting conclusions.

While the American Society of Anesthesiologists claims that this review proves their value as an anesthesia provider, nurses say that it only backs up their claims.

However, both anesthetics and CRNAs have a valued place in meeting the anesthesia needs of this country and when they are used in the right capacity. Not only can they take care of patients, now they can also do it in the most cost-effective way.

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CRNA vs. Anesthesiologist: Cost Effectiveness

Of course, all healthcare professionals looking to hire an anesthesiology care team hold an interest in comparing the cost-effectiveness of either CRNAs or anesthesiologists.

To do this, one would have to be aware of the average pay that either profession would expect to earn.

Anesthesiologist Annual Salary

According to the most recent Medscape compensation analysis for an anesthesiologist, the average annual salary is $398,000.

The Bureau of Labor Statistics has a much lower range for the salary of an anesthesiologist. According to their data, their average annual salary is only $262,000.

Of course, the actual market value of an anesthesiologist depends on many factors.

The Medscape report also revealed that 31% of anesthesiologists use nurse practitioners as part of their own practice.

Interestingly enough, only 8% of anesthesiologists who use NPs or PAs reported decreased profitability due to their hiring.

Example from Study

However, one study published by Economics, Education, and Health Systems Research used a wide variety of formulas to measure the cost-effectiveness of hiring an anesthesiologist.

This study compiled data that showed the added cost of hiring an anesthesiologist was worth the investment. The concluding paragraph of the publication sums the findings up succinctly.

“This study demonstrates that provider costs for physician-directed anesthesia are similar to provider costs for nonmedically directed nurse anesthesia and, when cost savings with reduced mortality are considered, physician anesthesia seems to decrease net health care costs. Even if all model assumptions are least favorable to physicians, these cost-effectiveness analyses suggest that incremental gains in life expectancy with a physician-directed versus nonmedically directed nurse model of care can be obtained at a cost deemed reasonable by society.”

It’s not just about how much money you can save, but the liability that would come with cutting these costs.

CRNA Annual Salary

The Bureau of Labor Statistics lists the annual salary of a CRNA as $181,000. If a CRNA specializes in outpatient care, they could earn as much as $224,000 in the United States.

While these numbers are lower than an anesthesiologist’s salary, it is above the average pay of a primary care doctor.

CRNAs can earn up to $227,000 in the five top-paying states:

1. Wyoming
2. Montana
3. Oregon
4. Wisconsin
5. California

Other Factors

Just as the median wage would differ depending on several factors for an anesthesiologist, the same is true of a CRNA.

• The number of years of nursing experience a CRNA has earned
• The location of the position
• The type of healthcare system

All these factors would affect the market value of a CRNA.

The Lewin Group conducted a study of the cost-effectiveness of hiring a CRNA. This study showed 25% more potential revenue versus the cost to employ a CRNA without supervision. (Of course, they prepared this study for the American Association of Nurse Anesthetists, so we can imagine that it would be somewhat biased.)

There’s no denying that CRNAs are cheaper to hire than anesthesiologists and should be employed in the best capacity to do a high volume of repetitive cases to increase productivity and revenue at a lower cost.

Do you work in one of the 10 Best States to Practice Medicine?

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Pros of Hiring an Anesthesiologist

An anesthesiologist is a trained doctor with extensive knowledge of medicine above and beyond just anesthesiology. This makes them better suited to make executive decisions when an emergency arises.

Anesthesiologists will always carry malpractice insurance. This covers much of the potential risks of a patient or family member suing for wrongful death or injury.

The residency that an anesthesiologist must complete (and the following optional fellowship) provides for much more hands-on practice of anesthesiology than that of a nurse anesthetist.

This prepares them well to take on the responsibility of all anesthesia practices. Further, it provides the opportunity for some to sub-specialize in various areas of anesthesiology.

For example, if an obstetrician wants to hire an anesthesiology professional, they could employ a doctor that completed a fellowship in obstetric anesthesiology.

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Pros of Hiring a CRNA

A CRNA is a viable money-saving alternative to hiring additional anesthesiologists if one cannot cover all your practice’s anesthesiology responsibilities.

As this article helps to prove, CRNAs come very well trained.

Due to the improvements in the technology of anesthesia practices, they can complete most of what an anesthesiologist can by merely following the near-perfect formula.

No matter how great a CRNA, their training cannot replace the expertise of an anesthesiologist and that is why anesthesiologists get paid more.

CRNAs are often younger than anesthesiologists when entering the field due to the fewer years of education needed. This gives them ample opportunity to gain valuable nursing experience early on.

Under physician supervision, CRNAs are undeniably a solid part of the anesthesia team. Their help allows for the completion of more surgeries each year, leading to an increase in profit margins for healthcare facilities.

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Understandably, there is a big worry about the safety of using a stand-alone CRNA as the only means of administering anesthetics. In no way would this article claim to deny the qualifications of an anesthesiologist.

However, when it comes to filling the ongoing need for cost-effective healthcare:

The extensive required training of a certified registered nurse anesthetist gives them plenty of expertise to be the sole provider of this care (although not to the extent of an anesthesiologist).

The advancement of research and development in anesthetic procedures has made anesthesiology much safer than in times past. Nurses and doctors use the exact same methods to administer anesthetics.

Conclusion

Of course, big inner-city hospitals may require an extensive team of anesthesiologists, anesthetic assistants, as well as CRNAs.

Smaller practices and rural areas that cannot afford these big teams (or lack anesthesiologists to oversee nurses) can still offer safe and effective anesthetic care with the employment of CRNAs (or multiple CRNAs overseen by just one anesthesiologist for complex cases).

In the end, it’s up to each healthcare practice to weigh the pros and cons of hiring a CRNA vs. anesthesiologist and make the best decision for their needs.

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