If Nurses Are Certified to Offer Anesthesia, Why Must a Doctor Watch Them Do It?

This article appeared on Arizona Republic on August 26, 2020.

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Many lessons can be learned from the flat‐​footed initial response by all levels of government to the COVID-19 pandemic. One is that health care license “scope of practice” laws block patients from receiving care from providers who are forbidden to practice to the full extent of their training.

Arizona Gov. Doug Ducey tacitly acknowledged this in March when he issued an executive order that allowed CRNAs (Certified Registered Nurse Anesthetists) to practice independent of physicians or surgeons.

As a result, Arizona joined 17 other states that have opted out of these federal guidelines since 2001. This added crucial personnel to the health care work force during this public health emergency. As a general surgeon, I am pleased with the way CRNAs give anesthesia to my patients.

The Centers for Medicare and Medicaid Services guidelines state nurse anesthetists should be “supervised” by a physician. This prevents these well‐​trained, specialized nurses from providing anesthesia independently and freeing up physician anesthesiologists so more patients can receive care.

But these guidelines are listed as “optional.” The governor decided that Arizona will opt out.

Rule change improves health care access

Maintaining this broadened scope of practice post pandemic will give people more health care options and access, particularly in underserved rural areas.

Unfortunately, in guild‐​like fashion, licensed physician anesthesiologists would like to see things return to the way they were once the crisis is over. They are petitioning the governor to declare the opt‐​out a temporary emergency measure.

This example of cronyism is nothing new. State legislators have been dealing with it for years.

For decades state legislators have witnessed turf battles among the various health care professions. For example, nurse practitioners and physician assistants seek to practice independent of physicians and to expand their scope of practice to meet their level of training.

Opponents want to protect their turf

Medical doctors usually oppose this, arguing nurse practitioners and physician assistants lack the necessary training to safely provide care beyond a narrowly defined scope. States vary in the degree to which they have widened the scope of practice of NPs and PAs.

Arizona is one of the better ones. It allows nurse practitioners to practice to the full extent of their training and gives wide latitude to physician assistants.

Similarly, state capitals witness battles between optometrists, who seek to expand their scope to include prescriptive authority and simple surgical authority, and ophthalmologists who claim such expansions are dangerous. 

Pharmacists are another health care profession seeing its scope gradually expanded. All 50 states allow pharmacists to vaccinate patients, varying on age limitations and types of vaccinations allowed. Rhode Island and Oregon let pharmacy technicians give vaccinations.

Slowly, states are easing rules

Several states let pharmacists prescribe oral contraceptives, and last fall California became the first state to allow pharmacists to prescribe HIV pre‐​exposure prophylaxis and post‐​exposure prophylaxis.

Pharmacists’ scope of practice can expand to include a host of services, including tuberculosis skin testing and interpretation; testing and prescribing meds for patients with influenza and other viral illnesses or common bacterial infections like strep throat; and extending routine non‐​controlled chronic medication prescriptions for an additional 30–60 days.

Dental therapists are an emerging profession analogous to nurse practitioners or physician assistants. They work in underserved communities today in Alaska, Minnesota, Washington, Arizona, Maine, Vermont and others. Unsurprisingly, the dental profession pushes back on letting dental therapists practice independently, claiming to be concerned only with patient safety.

Don’t scale this back after the pandemic

In each of the examples above — and the list is not exhaustive — resistance to reform usually comes from incumbent professions that would lose market share when health care consumers have more choices.

Sadly, this kind of behavior has gone on for centuries. French economist Frederic Bastiat, in a satirical essay in 1845, petitioned the French parliament on behalf of the nation’s candlemakers to enact protectionist laws against unfair competition from the sun.

Governor Ducey did the right thing when he allowed CRNAs to practice to the full extent of their training in this public health emergency. There is no good reason why they shouldn’t practice to the full extent of their training all the time.

Jeffrey A. Singer

Jeffrey A. Singer, MD, practices general surgery in Phoenix and is a senior fellow at the Cato Institute.