Post almost any study that is favorable to CRNA practice and the response is immediate:

“The AANA funded it.”

Sometimes it is even more direct:

“The AANA bought and paid for those results.”

That is usually where the analysis stops.

Nobody discusses the methodology. Nobody asks whether the outcome measures were appropriate. Nobody looks at the statistical analysis or whether the conclusions actually match the data. The AANA paid for it, so the results must be biased.

I see this constantly in anesthesia discussions, especially online. It happens on Reddit, in social-media debates, in advocacy materials, and anywhere else research involving CRNA practice is discussed.

Let me be clear: who paid for a study matters.

When a professional organization funds research that may advance its legislative or professional interests, that is a conflict of interest. It should be disclosed. It should make you look at the study a little sideways.

What it should not do is end the discussion before anyone reads the study.

Who else is going to pay for this research?

This is the part that often gets “lost in the sauce” I think.

Research is expensive. Large database studies require access to data, researchers, statisticians, health-policy experts, and a considerable amount of time. Depending on the project, the cost may be substantial. We are talking hundreds of thousands to millions of dollars.

There is also very little commercial value (none?) in studying whether CRNA scope-of-practice laws affect anesthesia complications.

A drug company has an obvious reason to pay for research involving its medication. If the study supports the drug, it may pass FDA scrutiny and then the company may sell more of it.

A medical-device company has the same basic incentive. It pays for research because positive findings may help it sell the device.

That does not automatically mean those studies are invalid either. It means you need to understand the sponsor’s interest and then look closely at the design, the outcome selection, the analysis, the publication process, and whether negative findings were reported.

But there is no drug being sold when someone studies whether CRNAs can practice safely without physician medical direction. There is no proprietary device generating a return on investment. No one is making profit as a result of these studies.

Having said that, the questions are still important because hospitals, legislators, administrators, and regulators keep asking them:

• Are CRNAs safe?

• Does the data show physician supervision requirements improve outcomes?

• Does expanded scope of practice increase anesthesia complications?

• Does the anesthesia delivery model affect cost or access?

Those questions are extremely important to us. They are important to rural hospitals and facilities struggling to maintain anesthesia coverage. They are important whenever scope-of-practice legislation is debated.

But who has a financial reason to spend the money to study them?

Usually, it is going to be the professional organizations representing the people directly affected by those policies. If CRNAs and the AANA do not support this research, much of it will probably never be done.

That does not mean the AANA doesn’t have an interest in the outcome. Of course it does. The AANA advocates for CRNA practice, full scope of practice, reimbursement, and professional autonomy. That interest should be stated openly.

But professional interest is not identical to direct commercial profit. Different conflicts create different incentives. They should be identified and evaluated for what they actually are instead of being lumped together as though every funding relationship has the same meaning.

The double standard is not subtle

In 2016, the American Society of Anesthesiologists published a two-page summary of research comparing anesthesia professionals.

Before getting into the individual studies, the document emphasized that four of the five studies it characterized as favorable to CRNAs had received AANA funding. It then highlighted AANA funding when criticizing the Dulisse and Cromwell study, Pine et al., Needleman and Minnick, and the Hogan cost-effectiveness analysis.

What stood out wasn’t that ASA disclosed the AANA funding. It was that they used it as one of the first reasons readers should doubt those studies, before discussing the methods or results.

That does not mean every criticism in the ASA document was wrong. Some of the criticisms are fair and should be considered.

Claims-based research has limitations. Risk adjustment is key. Billing modifiers are imperfect. A study should not claim more than its data support.

But look at how the funding gets used.

When the AANA funds a study, the funding source itself becomes one of the central criticisms.

When a study favors the ASA’s position, there is much less discussion of the professional, institutional, and economic interests involved in selecting that evidence and using it in advocacy.

Even the 2014 Cochrane review said funding can affect how research is published or interpreted. It also said that does not automatically invalidate the results.

And if we’re going to use that standard, it has to apply to the studies ASA likes too. Silber’s 2000 study is not a clean comparison of independent CRNA care versus physician anesthesiologist care. Its “undirected” category mixed together CRNA-only cases, cases supervised by non-anesthesiologist physicians, and unbilled cases. Its “directed” category also combined physician-anesthesiologist-only cases with medically directed CRNA cases. Even after adjustment, the study was still vulnerable to residual confounding, billing misclassification, differences in case complexity, and major differences between the hospitals where those patients received care.

The Memtsoudis study has a different problem. It looked at “unexpected disposition” after outpatient knee and shoulder procedures. That is not the same thing as measuring anesthesia-related mortality, major complications, or whether one type of anesthesia professional is safer than another. An unexpected admission can happen for all kinds of reasons, including pain, nausea, surgical issues, facility policy, social circumstances, or patient preference. That does not make the study worthless. It means the result should not be stretched into a broader claim than the outcome can support.

So does that make the study wrong? No. It just means don’t claim it says something it never studied.

The AANA does this too, by the way.

The Anesthesia Facts website is an advocacy-curated summary of studies that support CRNA safety, cost-effectiveness, access, and scope of practice. It is useful. It gives readers a place to find the research. But it is still an advocacy page.

It should not replace reading the original articles.

Neither should an ASA summary.

A study can have limitations without being worthless

Take the 2016 study titled Scope of Practice Laws and Anesthesia Complications: No Measurable Impact of Certified Registered Nurse Anesthetist Expanded Scope of Practice on Anesthesia-Related Complications.

This is one of the studies that is regularly dismissed because it received AANA support.

The investigators examined millions of commercial insurance claims from inpatient, outpatient, and ambulatory surgery settings. They evaluated whether coded anesthesia-related complications varied according to state scope-of-practice laws and anesthesia delivery model.

They reported no measurable increase in anesthesia-related complications associated with the expanded scope-of-practice classifications or delivery models they studied.

Does the study have limitations?

Of course it does, they ALL do!

It is an observational study. It uses administrative claims data, which exist primarily for billing rather than clinical research. Claims data may not capture every complication or every relevant difference in patient condition. The researchers could only adjust for variables available in the database.

The billing modifiers also do not tell us exactly how every anesthesia practice operated.

QZ billing means the CRNA service was billed without physician medical direction. It does not necessarily mean there was no physician anesthesiologist anywhere in the facility or affiliated with the group. It does not tell us whether a physician was available for consultation or had some other involvement.

A QZ practice might be an entirely independent CRNA practice. It could also involve CRNAs and physician anesthesiologists working in the same facility in different rooms without billing under the medical-direction requirements. It could be highly autonomous or relatively restrictive.

What QZ does tell us is that the federal medical-direction billing conditions were not applied to those services. That is important to note. But it does not describe every clinical detail of the practice.

Those are fair criticisms of the study.

What is not fair is identifying those limitations and then pretending the study tells us nothing.

That means the conclusion has to be narrower than some CRNAs want it to be. It does not mean the finding is meaningless.

Within a very large commercial claims database, the researchers did not identify a measurable increase in coded anesthesia-related complications associated with the scope-of-practice and delivery models they evaluated.

That does not prove every CRNA and every physician anesthesiologist is identical. It does not prove every delivery model has exactly the same outcome under every possible circumstance. It does not establish that claims data capture every clinically important anesthesia event.

We should not claim that it does.

But the study also does not become invalid simply because the AANA helped pay for it.

This is where these arguments get ridiculous. Someone finds one limitation and suddenly the whole study has been “debunked.”

Every observational health-services study has limitations.

The real question is whether the limitation is serious enough to invalidate the finding, whether it may have biased the result, and how much it should narrow the conclusion.

Sometimes the study just cannot support the biggest claim people want to make from it.

That does not mean it tells us nothing. It may still give us useful evidence within a much narrower lane.

That is what actual critical appraisal looks like.

Now apply the same standard to the other side

The 2018 care-team study by Sun and colleagues is a good example.

I recently wrote about this study because the ASA and anesthesiologist assistant organizations routinely use it as evidence that CRNAs and AAs are equivalent anesthesia providers.

That is not what the study examined.

The researchers compared physician-anesthesiologist-supervised care teams using CRNAs with physician-anesthesiologist-supervised teams using anesthesiologist assistants.

The outcomes included mortality, hospital length of stay, and spending in an older Medicare population.

The study did not compare independent CRNA practice with AA practice because AAs cannot practice independently of a physician anesthesiologist.

It did not evaluate independent crisis management.

It did not establish educational equivalence.

It did not examine whether CRNAs and AAs are interchangeable across all anesthesia environments.

It did not evaluate access to care, autonomous decision-making, or the full professional capabilities of the two groups.

It compared two types of workers functioning inside a physician-anesthesiologist-supervised anesthesia care team and found no significant difference in the broad hospital outcomes it selected.

That is what it studied.

Whether or not the investigators intended it as advocacy, it was a narrow comparison using broad hospital metrics that were not especially anesthesia-specific. The ASA, the AAAA, and many of their members have since turned it into a much broader claim that the study did not establish.

That is the problem.

I am not rejecting the study because of who supported it. I am looking at the methodology, the population, the outcomes, and the conclusions that can reasonably be drawn.

Here’s the point. A study can be perfectly legitimate for the question it actually asked and still get completely oversold afterward. That’s what I think happened here. The problem isn’t always the study itself. Sometimes it’s what people start claiming the study proves.

We have to apply this to ourselves too

CRNAs are not immune to this problem.

We sometimes share a favorable title or abstract without reading the entire paper. We sometimes take a single observational study and present it as though it settles every question involving safety, independent practice, or anesthesia delivery models.

That is not good enough.

We cannot demand that everyone else read the research critically while we accept every study that helps our side without asking the same questions.

We should be willing to say:

• This is what the study examined.

• This is what it found.

• These are its limitations.

• This is what the evidence reasonably supports.

• This is what it does not support.

• Then we can explain why the finding still matters.

That is a much stronger position than pretending every study we like is perfect. None of them are.

There is an economic interest here

Look, I don’t think it’s rocket science that the ASA’s interest in this argument is not just about academics.

There’s no way around it. Correcting scope of practice laws, removing antiquated supervision mandates, eliminating costly medical direction style practices absolutely directly affects physician anesthesiologist employment, demand, negotiating leverage, and at the bottom line, wallets.

Look, physician anesthesiologists are generally paid two to three times more than CRNAs in the same labor market. Any anesthesia model that does not require a physician anesthesiologist to participate in or direct the work of multiple CRNAs truly protects their positions and revenue. If the model were to change due to eliminations of barriers to practice for CRNAs and hospitals, along with changes in state laws or requirements that make them feel more comfortable, that would directly impact the bottom line of physician anesthesiologists. This is because the positions they rely on may decrease in avaliability.

That is a clear economic interest. It deserves disclosure and scrutiny just as AANA’s professional interest does.

CRNAs have interests too. Broader scope of practice may affect autonomy, employment options, compensation, and bargaining power.

This is not a situation where one side has a conflict and the other side somehow doesn’t.

The problem is that ASA frequently presents AANA’s interest as inherently disqualifying while paying far less attention to its own interest in maintaining physician-mandated delivery models.

Any reasonable observer can’t look at the way all of this is framed from the 30,000-foot view of the market, the actual preponderance of evidence pertaining to safety and outcomes, and believe this looks like a patient safety or academic disagreement. The more you hear the arguments, the more and more it starts to sound like trade protectionism. Which, by the way, is totally okay as long as you disclose that that is you’re lens in the first place.

At the end of the day, facilities should be able to choose the anesthesia model that works best for their patients, their workforce, their finances, and the laws in their state.

Research should inform that choice.

Fearmongering and selective descriptions of research should not.

Ask whether the study supports the claim being sold

There is literally no chance that legislators and administrators are going to sit down and do a statistical review of every anesthesia study handed to them.

I understand that.

But they should at least ask better questions.

1. What did the study actually compare?

2. Did it measure outcomes that relate to the policy being debated?

3. Were the patients and facilities comparable?

4. Did the sponsor participate in the design, analysis, publication decision, or messaging?

5. Did the researchers adjust for important differences?

6. Is the association’s summary broader than the original article?

7. Is this one study standing by itself, or does it fit with the rest of the evidence?

Most importantly:

At the end of the day, I don’t really care whether the AANA paid for a study, the ASA paid for a study, or a drug company paid for a study.

I care whether the study actually says what people keep claiming it says.

Maybe we’ve been asking the wrong question all along.

Instead of asking, “Who paid for the study?”

Maybe we should start asking,

“Did you actually read it?”

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Most people learned what “supervision” meant at their first job. Maybe it was a fast-food restaurant, a grocery store, or some other hourly position. The supervisor told you what to do, controlled how you did it, and was responsible for what happened during the shift.

That is the ordinary meaning people bring to the CMS opt-out discussion. They hear that a CRNA must be “supervised” and assume someone else must control the anesthetic, direct the CRNA’s decisions, and accept responsibility for the CRNA’s actions.

That is not what the CMS regulation says.

What opt-out actually is

CMS is the Centers for Medicare & Medicaid Services. Hospitals that participate in Medicare must comply with federal Conditions of Participation. One of those conditions says that, unless a state has opted out, a CRNA administering anesthesia must be under the supervision of either the operating practitioner or a physician anesthesiologist who is immediately available if needed.

A state opts out when the governor sends CMS a letter requesting exemption from that specific federal supervision requirement. The governor must consult with the state boards of medicine and nursing and attest that opt-out is in the best interests of the state’s citizens and is consistent with state law.[1]

Opt-out does not create independent CRNA practice. It does not expand state scope of practice, issue privileges, change professional billing, or require a hospital to adopt a particular anesthesia model.

Those issues continue to be governed by state law, licensure, credentialing, delineation of privileges, medical staff bylaws, and the policies of each individual facility. The governor cannot use opt-out to override state law. The state’s legal framework must already be compatible with removing the federal supervision requirement.

Before opt-out, CRNA practice is determined by those state and local requirements. After opt-out, CRNA practice is still determined by those same requirements. The clinical authority does not come from the opt-out letter.

As of July 2026, 26 states have formally exercised the CMS opt-out, either statewide or for specified facilities. Guam has also opted out. Vermont became the 26th state in July 2026, meaning more than half of the states have now chosen to remove this federal supervision requirement.

What CMS supervision does not mean

The word “supervision” is where the problem begins.

The CMS regulation does not say the operating practitioner controls the CRNA’s anesthetic. It does not say the operating practitioner chooses the anesthetic technique, approves the anesthetic plan, directs medications, dictates clinical decisions, or can overrule the CRNA’s judgment.

It also does not say that the operating practitioner becomes liable for the CRNA’s actions simply because CMS uses the word “supervision.”

State law, employment relationships, contracts, privileges, hospital policies, and the actual conduct of the people involved can create duties and affect liability. The CMS supervision requirement does not create those relationships.

When CMS directly addressed surgeons’ concerns about liability during its anesthesia rulemaking, it stated that changing the federal supervision requirement made no legal change in the scope of malpractice liability. CMS explained that liability remained dependent on state law and the facts and circumstances of the individual case.[4]

In other words, the presence of the word “supervision” does not automatically create liability. It is not a malpractice rule.

The same applies to control. The CMS requirement does not make the operating practitioner the CRNA’s boss. It does not create an employer-employee relationship, an agency relationship, or authority over the CRNA’s clinical judgment.

CMS guidance tells hospitals to establish their own policies for supervision by the operating practitioner and to base those policies on generally accepted standards of anesthesia care. CMS does not provide a federal checklist of actions the operating practitioner must perform. It does not require the operating practitioner to evaluate the patient for anesthesia, formulate the anesthetic plan, select medications, monitor the anesthetic, sign the CRNA’s record, or participate in the CRNA’s clinical decisions.[2]

Depending on state law and hospital policy, the operating practitioner’s role may be as limited as ordering or requesting anesthesia services and performing the procedure while the CRNA provides the entire anesthesia service. CMS has long recognized that a CRNA can furnish the entire anesthesia service without medical direction while still being considered under the supervision of the operating surgeon.[4]

That distinction is important. Supervision under the facility rule is not the same thing as medical direction of the anesthetic.

CMS’s current coding guidance recognizes that CRNAs may provide anesthesia independently or under the supervision of an operating practitioner or physician anesthesiologist. It also separately recognizes non-medically directed CRNA services. A CRNA can therefore provide the entire professional anesthesia service without medical direction even when the facility is located in a non-opt-out state.[3]

The professional anesthesia bill does not become medically directed simply because the facility satisfies the CMS supervision requirement through the operating practitioner. Opt-out status and professional billing status are separate issues.

The real issue is perception

None of that is obvious to the average hospital administrator, surgeon, board member, or risk manager.

They see the word “supervision” and interpret it the way most people would. They assume supervision means control. They assume control means responsibility. They assume responsibility means liability.

That interpretation is understandable, but it is not found in the CMS regulation.

This is also where the supervision language becomes politically useful for those who oppose CRNA practice. The word can be presented as proof that federal law requires physician control, physician oversight of the anesthetic, or physician responsibility for the CRNA. The regulation does not establish any of those things, but most people will never read far enough into the rule to understand the distinction.

They simply hear “supervision.”

That perception influences hospital decisions. A facility may be legally able to use a non-medically directed CRNA model under state law but remain hesitant because administrators believe the federal supervision language creates a relationship or liability that does not actually exist.

Opt-out removes that source of confusion.

It does not force a hospital to use a CRNA-only model. It does not prohibit medical direction, remove physician anesthesiologists, or prevent collaboration. A hospital may continue using exactly the same anesthesia model it used before the state opted out.

What opt-out does is remove one federal barrier to local control. It allows each facility to select the anesthesia model that fits its patients, workforce, finances, surgical services, and community without a vague federal supervision requirement distorting the discussion.

In many facilities, nothing about the actual delivery of anesthesia changes when a state opts out. The CRNAs have the same licenses, the same credentials, the same privileges, and the same responsibilities the day after opt-out that they had the day before.

What changes is the federal word. “Supervision”

That word never created independent practice, clinical control, medical direction, or automatic liability. It created the perception that those relationships might exist.

Removing it takes away one more argument that hospitals do not have the authority to make their own decisions. It allows state law, hospital credentialing, delineation of privileges, and local policy to determine the anesthesia model without the baggage attached to the word “supervision.”

That is what CMS opt-out is really about.

References

1. Electronic Code of Federal Regulations. 42 CFR § 482.52, Condition of Participation: Anesthesia Services.
   https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-482/subpart-D/section-482.52

2. Centers for Medicare & Medicaid Services. State Operations Manual, Appendix A, Survey Protocol, Regulations and Interpretive Guidelines for Hospitals. See § 482.52, Anesthesia Services.
   https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/som107ap_a_hospitals.pdf

3. Centers for Medicare & Medicaid Services. Medicare NCCI 2026 Coding Policy Manual, Chapter 2, Anesthesia Services.
   https://www.cms.gov/files/document/02-chapter2-ncci-medicare-policy-manual-2026-final.pdf

4. Health Care Financing Administration. Medicare and Medicaid Programs; Hospital Conditions of Participation: Anesthesia Services. Federal Register, January 18, 2001.
   https://www.govinfo.gov/content/pkg/FR-2001-01-18/html/01-1388.htm

5. Centers for Medicare & Medicaid Services. Medicare and Medicaid Programs; Hospital Conditions of Participation: Anesthesia Services. Federal Register, November 13, 2001.
   https://www.govinfo.gov/content/pkg/FR-2001-11-13/html/01-28439.htm

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One of the studies most commonly cited in support of anesthesiologist assistant expansion is the 2018 Anesthesiology article, Anesthesia Care Team Composition and Surgical Outcomes, by Sun and colleagues. It gets used in legislative testimony, talking points, advocacy materials, and hallway debates as if it settles a much larger question: whether AAs and CRNAs produce equivalent anesthesia outcomes.

That is not what the study proves.

The paper is worth reading carefully because the problem is not necessarily the study itself. The problem is what people keep trying to make it say. The article examined a very specific question in a very specific setting: whether inpatient Medicare outcomes differed when a physician anesthesiologist supervised an AA versus when a physician anesthesiologist supervised a CRNA. That is a supervised anesthesia care team study. It is not a direct comparison of CRNA practice and AA practice across modern anesthesia delivery.

That design choice changes what the paper can honestly tell us. When both comparison groups include physician anesthesiologist supervision, the study cannot isolate the independent clinical contribution of either the CRNA or the AA. The physician anesthesiologist is built into both sides of the comparison. So when this paper is used as proof that AAs and CRNAs are interchangeable, the claim has already gone beyond the study design.

What the Study Actually Looked At

The study evaluated 443,098 Medicare inpatient surgical cases from 2004 through 2011. The population was elderly Medicare patients, ages 65 to 89, undergoing inpatient surgery in states where AAs were permitted to practice during the study period.

The comparison was physician anesthesiologist plus AA versus physician anesthesiologist plus CRNA. Those are two physician anesthesiologist-supervised care team configurations. The study did not compare independent CRNA care to AA care. It did not compare CRNA-only models to AA models. It did not compare rural anesthesia models, collaborative models, obstetric models, outpatient anesthesia, pediatric anesthesia, or modern staffing arrangements.

The outcomes were also limited. The authors measured inpatient mortality, inpatient length of stay, and inpatient spending. These are broad hospital outcomes. They are not anesthesia-specific outcomes. The paper did not measure airway events, aspiration, awareness, rescue calls, medication errors, PACU complications, ICU escalation, hemodynamic instability, failure-to-rescue, or whether the anesthesia professional recognized and managed a developing crisis.

Those details are exactly where anesthesia care often lives. A patient can have an anesthesia-related complication that is rescued successfully and never appears as inpatient mortality. A difficult airway can be managed well or poorly without changing length of stay. A near-miss can be clinically important and completely invisible in claims data. A study built around mortality, length of stay, and spending is not designed to answer whether two anesthesia professionals have equivalent clinical training, judgment, independence, or capability.

What the Study Found

The study found no statistically significant differences in the three measured inpatient outcomes. Adjusted inpatient mortality was 1.7% in the CRNA-team group and 1.6% in the AA-team group. Adjusted length of stay was essentially the same. Adjusted inpatient spending differed by about $56, which was also not statistically significant.

A careful summary would be: in this claims-based study of elderly Medicare inpatients receiving care in physician anesthesiologist-supervised teams, the specific supervised team member was not associated with statistically significant differences in inpatient mortality, length of stay, or inpatient spending.

That is a reasonable conclusion. It is also much narrower than the way this article often gets used publicly. The study did not show that AA care and CRNA care are equivalent. It showed that two supervised care team configurations did not differ on three broad inpatient outcomes in one retrospective claims-data analysis.

Weaponized social media summaries intentionally blur that distinction.

The Physician Anesthesiologist Was Present in Both Groups

The central limitation of using this article for AA-versus-CRNA advocacy is that both study groups included physician anesthesiologist supervision. The authors were not comparing independently practicing CRNAs to AAs. They were not comparing CRNA-only models to AA models. They were not comparing rural CRNA practice to urban ACT practice. They were not evaluating what happens when no physician anesthesiologist is present.

They compared two versions of the physician anesthesiologist-supervised ACT model.

That makes the article more relevant to the internal structure of the ACT model than to the broader question of CRNA and AA equivalence. If ASA wants to argue that, under physician anesthesiologist supervision, the measured hospital outcomes in this dataset were similar, that is a fair reading. If the argument becomes “this proves AAs and CRNAs are equivalent,” the study is being stretched past its actual findings.

The authors themselves were careful on this point. They noted that team structures and physician supervision may mitigate any systematic differences between AAs and CRNAs, if such differences exist. That is very different from proving there are no meaningful differences between the two professions. A supervised system can reduce variation because the system itself is designed to buffer differences in training, experience, scope, and judgment.

That is supervision. It is not proof of provider equivalence.

The Study Does Not Tell Us How Involved the Physician Anesthesiologist Was

One of the biggest problems with using this article as a CRNA-versus-AA comparison is that a physician anesthesiologist was involved in every case group by design. That structure may be useful if the question is limited to supervised ACT composition, but it creates a major blind spot if the claim is professional equivalence.

The study does not tell us how much physician anesthesiologist involvement occurred in either group. It does not tell us whether the physician anesthesiologist spent more time in AA rooms than CRNA rooms. It does not tell us whether AAs required more direction, more correction, more rescue, or more real-time intervention than CRNAs.

That missing information changes what can honestly be claimed from the paper. If physician anesthesiologists were more involved in AA cases, then the study would not be measuring equivalent AA and CRNA performance. It would be measuring the outcome of a system where physician anesthesiologist involvement may have compensated for differences in training, scope, experience, or independence. The authors’ own framing leaves room for that possibility when they discuss supervision and team structure as mechanisms that may mitigate differences.

The same issue runs in the other direction. If physician anesthesiologists were minimally involved in both groups, the study still does not show what happened clinically inside the anesthetic. Claims data cannot tell us who recognized the problem, who made the key decision, who managed the airway, who treated the hypotension, who called for help, or who rescued the patient before a bad outcome occurred.

The “physician anesthesiologist was involved” point cuts both ways. It prevents the study from isolating the independent contribution of the CRNA or the AA, and it also prevents the study from proving the independent value of physician anesthesiologist involvement itself. The physician anesthesiologist is present in the billing structure, but the actual degree of clinical involvement is not measured.

A study that cannot account for physician anesthesiologist involvement cannot be used to claim that AAs and CRNAs perform the same clinically. At most, it can say that in this dataset, two physician anesthesiologist-supervised team configurations had similar broad inpatient outcomes.

Inpatient Mortality Is Too Broad to Prove Anesthesia Equivalence

The study used inpatient mortality as one of its three primary outcomes. That sounds powerful because mortality is obviously important, but inpatient mortality is a broad hospital endpoint. It captures whether the patient died at any point during the hospitalization. It does not tell us whether the death was caused by anesthesia care, surgical care, postoperative management, medical disease, trauma burden, or progression of the condition that brought the patient to surgery.

In practical terms, the mortality window extends from the operating room through the rest of the inpatient stay. A patient could die days later from sepsis, hemorrhage, pulmonary embolism, myocardial infarction, stroke, ICU complications, withdrawal of care, malignancy, frailty, or the severity of the original injury. Those deaths may have little or nothing to do with the anesthesia professional in the room.

That is especially relevant in an elderly Medicare inpatient population. These patients are often sicker, more fragile, and more likely to have complicated postoperative courses. Their risk of death is influenced by surgical urgency, baseline comorbidities, hospital resources, ICU care, nursing care, source control, postoperative complications, and goals-of-care decisions. None of that can be separated cleanly from the anesthesia claim used to classify the care team.

The article also does not tell us whether anesthesia-related mortality differed between groups. If one group had more airway events, aspiration events, hemodynamic collapses, medication errors, or rescue failures that contributed to death, we would not know from the primary endpoint. The study reports inpatient mortality, not anesthesia-attributable mortality.

The same problem applies to length of stay and spending. A longer admission may reflect surgical complications, infection, discharge barriers, rehabilitation needs, ICU bed availability, social issues, or severity of injury. Higher spending may reflect the same things. Without knowing why the patient stayed longer or why the hospitalization cost more, those endpoints cannot be used to make claims about anesthesia provider equivalence.

For this workforce debate, the more relevant outcomes would be anesthesia-specific complications, rescue calls, airway events, aspiration, awareness, PACU respiratory events, unplanned postoperative ventilation related to anesthesia, intraoperative hemodynamic instability, medication errors, regional anesthesia complications, and documented physician anesthesiologist intervention. The Sun study did not measure those outcomes.

Mortality, length of stay, and spending may be reasonable endpoints for a broad health services research question. They are not enough to prove that AAs and CRNAs are clinically equivalent anesthesia professionals.

The Study Did Not Measure the Outcomes People Usually Care About in Anesthesia

When hospital leaders, legislators, and anesthesia professionals talk about safety, they are usually not limiting the conversation to inpatient mortality, length of stay, and spending. They are talking about whether the person providing anesthesia can manage the case in front of them, anticipate deterioration, rescue complications, and make appropriate decisions when things change quickly.

This study does not tell us whether an AA and a CRNA are equivalent in airway management, crisis recognition, independent judgment, preoperative assessment, emergence planning, regional anesthesia, obstetrics, pediatrics, outpatient anesthesia, office-based anesthesia, trauma, rural coverage, or critical access hospital practice.

It also does not identify whether an adverse event was related to anesthesia, surgery, medical disease, nursing care, hospital resources, postoperative management, or discharge planning. A claims-based inpatient mortality endpoint cannot answer those questions.

That does not make the study useless. It makes the study limited. The problem is pretending those limits do not exist.

The AA Group Was a Small Part of the Final Sample

The final sample included 421,230 CRNA-team cases and 21,868 AA-team cases. AA-team cases represented about 4.9% of the final analytic sample.

That point should not be exaggerated. The AA group was still large enough to study in the context of the authors’ model. But it is relevant when the paper is presented as a sweeping national statement about anesthesia workforce policy. The study was based on a relatively small AA-team share, drawn from AA-permitted states, during a historical period that ended in 2011, using traditional Medicare inpatient claims.

That is a narrow slice of anesthesia practice. It does not automatically generalize to today’s outpatient-heavy surgical environment, obstetric units, pediatric anesthesia, GI centers, office-based anesthesia, rural hospitals, private-payer populations, or modern staffing economics.

Case Assignment Still Leaves an Unanswered Question

The authors used risk adjustment, hospital fixed effects, and an instrumental-variable approach to reduce confounding. That is better than a simple unadjusted comparison. Still, the paper acknowledges the possibility of residual confounding and specifically notes that unobservable differences in patient complexity and case assignment could remain.

That limitation is important because anesthesia staffing is not random in real life. Sicker patients, more complex procedures, difficult surgeons, unstable trauma cases, complex vascular cases, major abdominal procedures, and high-risk emergencies may not be distributed evenly between provider groups. A department may assign certain rooms, surgeons, procedures, or patient types differently based on staffing, experience, trust, supervision needs, or institutional habit.

If CRNAs were assigned more difficult cases and AAs were assigned less complex cases, the study may understate CRNA performance. If AAs were assigned more difficult cases but received more direct physician anesthesiologist involvement, the study may reflect physician-supported team performance more than AA performance. The claims data cannot resolve that.

The authors tried to address measurable differences. That is appropriate. But measurable differences are not the same as all clinically meaningful differences. In anesthesia, the variables that matter most are often not fully captured in administrative claims: airway difficulty, induction instability, bleeding trajectory, urgency, surgeon behavior, room assignment, supervision intensity, real-time rescue, and who actually made the critical decisions.

The study also could not control for provider experience. That is a major limitation in anesthesia because the label attached to the billing claim does not tell us whether the person in the room had one year of experience or twenty. It does not tell us whether the provider routinely handled high-acuity vascular cases, obstetrics, pediatrics, trauma, independent call, regional anesthesia, or complex airways. It also does not tell us whether a less experienced provider received more direct physician anesthesiologist involvement than a more experienced provider.

That matters clinically because experience changes the entire supervision equation. A new provider may need more direction, more backup, more prompting, and more rescue than a provider who has managed thousands of anesthetics across multiple practice settings. If one group had more experienced providers and the other group had less experienced providers but more physician anesthesiologist support, the study would not be measuring true provider equivalence. It would be measuring a mixture of provider type, experience level, case assignment, and unmeasured physician anesthesiologist involvement.

Claims data cannot separate those variables.

The Study Could Not Evaluate Supervision Ratios

One of the most important practical issues in ACT staffing is supervision ratio. A physician anesthesiologist supervising one room is not the same operational model as a physician anesthesiologist medically directing four rooms. Availability, response time, case complexity, induction and emergence overlap, and competing demands all change as the number of concurrent rooms changes.

The Sun study could not measure supervision ratios. The authors acknowledged that limitation directly, noting that their data did not allow them to adjust for differences in supervision ratios between AA and CRNA care teams.

That limitation is important even within Medicare’s medical direction framework. Medicare billing can identify medical direction categories, but the billing structure does not give the clinical detail needed to know whether AA and CRNA cases were distributed similarly across 1:1, 1:2, 1:3, or 1:4 coverage. A medically directed AA case and a medically directed CRNA case may both appear as supervised team care, but the study does not tell us whether one group received closer physician anesthesiologist coverage than the other.

That leaves a major unanswered question. If AA cases were more often supervised 1:1 or 1:2 while CRNA cases were more often managed at 1:3 or 1:4, similar broad hospital outcomes would not prove equivalent provider performance. They could reflect different levels of physician anesthesiologist involvement. The same problem applies if one provider group required more rescue, more direction, or more real-time correction during the case. The study did not measure that.

If the claimed benefit of the AA model is physician anesthesiologist supervision, then the intensity and availability of that supervision cannot be treated as a background detail. It is central to the model. The Sun article did not control for it.

It Does Not Address Independent CRNA Practice

This is one of the biggest overextensions of the article. The study has nothing to say about independent CRNA practice.

The authors excluded certain opt-out state cases after opt-out because the purpose was to compare physician anesthesiologist-supervised care teams. That design choice makes sense for the study they were conducting. But it also means the article cannot be cited as evidence against independent CRNA practice, CRNA-only models, collaborative practice, or rural models where CRNAs provide the anesthesia coverage.

CRNAs practice in every state and in many different care models. AAs do not. AAs are legally dependent on physician anesthesiologist supervision. That structural difference is central to the workforce debate, but the 2018 article was not designed to evaluate it.

So when someone uses this paper to imply that AA expansion is equivalent to CRNA practice across the healthcare system, they are skipping over the most important operational difference between the two professions.

It Does Not Prove AA Expansion Improves Access

AA expansion is often sold as a solution to anesthesia access problems. This article does not prove that claim.

The authors themselves identified access and competition as areas for future research. That means the study did not show that introducing AAs improves access to surgical care, improves rural coverage, reduces cancelled cases, lowers anesthesia costs, stabilizes call coverage, or expands services in underserved communities.

Those are separate policy questions. They require different data.

A study showing no statistically significant difference in inpatient mortality, length of stay, and spending inside supervised ACT models does not tell us whether adding a legally dependent anesthesia provider improves access. In many settings, especially rural and underserved areas, mandatory physician anesthesiologist supervision may be the limiting factor rather than the solution.

For CRNAs, the access argument has always been tied to flexibility. CRNAs can work in physician anesthesiologist-led teams, collaborative models, CRNA-only groups, rural hospitals, critical access facilities, obstetric units, and independent practice environments. AAs cannot provide that same flexibility because their practice is legally tethered to physician anesthesiologist supervision.

The Sun article does not resolve that workforce issue.

The Study Was ASA-Funded

The article disclosed ASA funding, and one of the authors was employed by ASA. The paper also states that the Stanford investigators retained final control over the study design, manuscript, and publication decisions.

That disclosure should be handled fairly. Funding does not automatically invalidate a study. Industry and professional organizations fund research all the time. The question is not whether the article should be dismissed because ASA funded it. The better question is whether the study’s conclusions are being used within the limits of the study design.

In this case, the major issue is not the funding disclosure. The issue is the advocacy leap that followed. A narrow claims-based study using broad inpatient hospital metrics became a sweeping claim about professional equivalence. The study measured mortality, length of stay, and spending. It did not measure anesthesia-specific anything. That is not a small limitation. That is the difference between what the paper studied and what ASA/AAAA advocates keep claiming it proved.

A More Honest Way to Cite the Study

If someone wants to cite the article accurately, the language should look something like this:

The 2018 Sun et al. study found no statistically significant difference in inpatient mortality, inpatient length of stay, or inpatient spending between physician anesthesiologist-supervised teams involving AAs and physician anesthesiologist-supervised teams involving CRNAs among elderly Medicare inpatient surgical patients from 2004 through 2011.

That is accurate.

Here is what the article should not be used to claim:

The study does not prove that AAs and CRNAs are equivalent anesthesia professionals. It does not evaluate independent CRNA practice. It does not evaluate CRNA-only models. It does not evaluate AA practice without physician anesthesiologist supervision. It does not measure anesthesia-specific complications. It does not measure supervision ratios. It does not prove AA expansion improves access. It does not prove AA expansion lowers total anesthesia costs. It does not address whether AAs can replace CRNAs across the full range of anesthesia practice.

That is the difference between reading the article and weaponizing the headline.

The Simple Response When This Study Gets Quoted

When this article gets cited as proof that AAs and CRNAs have equivalent outcomes, the response does not need to be complicated:

The study compared two physician anesthesiologist-supervised ACT models in elderly Medicare inpatient cases. It measured inpatient mortality, length of stay, and spending. It did not compare independent CRNA practice to AA practice, did not measure anesthesia-specific complications, did not evaluate supervision ratios, did not control for provider experience, did not measure physician anesthesiologist rescue or intervention, and did not answer whether AAs and CRNAs are equivalent across anesthesia practice.

That is the cleanest way to bring the discussion back to what the paper actually says.

Bottom Line

The 2018 Anesthesiology article is a supervised ACT composition study. The study only evaluated general inpatient mortality, length of stay, and spending - that happened to use medical direction models - it had no anesthesia or surgical specific claims.

That finding should not be inflated into a claim that AAs and CRNAs are clinically equivalent, interchangeable, or equally capable across all anesthesia practice models.

The study does not answer that question.

And when ASA or AA advocates use it that way, they are not citing the study accurately. They are using a narrow claims-data article to support a broader policy claim the article was never designed to prove.

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The American College of Physicians recently published a policy paper arguing that physicians should not be referred to as “providers.” On that point, I agree with them.

“Provider” is a vague corporate term. It does not tell a patient who is actually standing in front of them, what license that person holds, what education they completed, or what role they are playing in the patient’s care. It is the kind of language that makes clinicians easier to treat as interchangeable labor units, which is not good for patients or professionals.

But if we are going to say names matter, then names have to matter for everyone. This is where the discussion becomes more complicated. The objection to “provider” is framed as a transparency issue, but the objection to titles like “nurse anesthesiologist” and “Physician Associate” often seems to operate by a different standard. Physician anesthesiologist is accepted. Dentist anesthesiologist is accepted. Certified Anesthesiologist Assistant is accepted. Yet nurse anesthesiologist is treated as uniquely confusing, even though the word “nurse” is right there in the title.

That inconsistency is the point. If the concern is truly patient understanding, then the solution should be precise titles for everyone, not selective title protection for some.

The Problem with “Provider”

I have never liked the term “provider.” It is impersonal, imprecise, and transactional. It sounds less like a professional identity and more like a line item in a staffing spreadsheet. In that sense, physicians are right to object to it.

The term also blurs meaningful differences in education, licensure, certification, scope, accountability, and role. A patient should not have to decode who is caring for them by guessing from a generic label. They should be told directly. But that principle cannot stop at physicians. If “provider” is not good enough because it hides professional identity, then the answer is not to reserve precise language for one profession while expecting everyone else to accept broader, vaguer, or more subordinate labels. The answer is to be specific about everyone.

A physician should be called a physician. A CRNA should be called a CRNA. A dentist should be called a dentist. A physician anesthesiologist should be called a physician anesthesiologist. A dentist anesthesiologist should be called a dentist anesthesiologist. A nurse anesthesiologist should be called a nurse anesthesiologist.

That is not confusion; it is clarification. The title identifies the clinical domain, and the modifier tells the patient the professional pathway. Together, they give the patient more information, not less.

Doctor Is Not the Same as Physician

A major problem in these debates is that “doctor” and “physician” are often treated as though they are interchangeable. They are not.

“Doctor” is an academic and professional title earned through completion of a doctoral degree. “Physician” is a licensure-based professional identity tied to MD or DO education and medical practice. Those two realities can coexist without threatening either one.

A person with an MD or DO is a physician. A person with a doctorate has earned the title doctor, subject of course to applicable state law, facility policy, and appropriate disclosure of credentials and discipline.

The ethical solution is not to erase doctoral education from every non-physician profession. The ethical solution is to disclose clearly. “Dr. Jane Smith, DNP, CRNA, nurse anesthesiologist” tells the patient much more than “your anesthesia provider will see you now.” It identifies the doctorate, the credential, the discipline, and the role. The same is true for “Dr. John Smith, MD, physician anesthesiologist” or “Dr. Alex Lee, DDS, dentist anesthesiologist.” Each title is specific. Each title discloses the professional pathway. Each title helps the patient understand who is involved in their care.

That is transparency.

The Anesthesia Title Debate Exposes the Inconsistency

Anesthesia is a useful place to test whether the concern is truly patient confusion, because multiple professions practice in the same clinical space.

Physician anesthesiologist is a descriptive title. It tells the patient that the anesthesia professional is a physician practicing anesthesiology. Dentist anesthesiologist is also a descriptive title. It tells the patient that the anesthesia professional is a dentist practicing anesthesiology. Nurse anesthesiologist is no different in structure. It tells the patient that the anesthesia professional is a nurse practicing anesthesiology as a CRNA.

This is why the objection to “nurse anesthesiologist” is hard to reconcile with the widespread use of “physician anesthesiologist.” Once the modifier is accepted in one context, the argument has already conceded that “anesthesiologist” can function as a practice-domain descriptor clarified by the professional pathway in front of it.

That is exactly what “nurse anesthesiologist” does.

The Timeline Matters

There is also a common misconception in this debate that deserves to be corrected. The story often gets told as though CRNAs created “nurse anesthesiologist” first in order to sound like physician anesthesiologists, and that “physician anesthesiologist” emerged later as a defensive response.

That is not the chronology.

The term “physician anesthesiologist” was already being used in organized anesthesiology messaging years before the AANA formally recognized “nurse anesthesiologist” as a descriptor. ASA’s public-facing “When Seconds Count” materials used “physician anesthesiologist” in the 2013-era public messaging around physician-led anesthesia care. AANA’s formal recognition of “nurse anesthesiologist” came later, with the Board’s 2019 recognition of the descriptor, the 2020 member resolution, and the 2021 organizational rebrand.

That changes the frame. The title “nurse anesthesiologist” did not invent the modifier structure. Organized medicine had already normalized that structure through the use of “physician anesthesiologist.”

Once “physician anesthesiologist” became acceptable, the logic was already established: the professional pathway comes first, and the anesthesia domain follows. Physician anesthesiologist. Dentist anesthesiologist. Nurse anesthesiologist.

The modifier is not a trick. It is the clarification.

That is also why the claim that “nurse anesthesiologist” is inherently misleading has always struck me as overstated. It says nurse. It identifies the profession. It ties the professional identity to the actual clinical domain of anesthesia and anesthesiology. It can be paired with CRNA, doctorate, license, and role disclosure. That is more transparent than telling a patient that their “anesthesia provider” will be in shortly.

There is also public-perception evidence that complicates the claim that patients are automatically confused by the term. A national survey of over 4000 registered voters commissioned during the title debate found that respondents were more likely to select “nurse anesthesiologist” than “nurse anesthetist” as the term that best described a professional nurse who provides anesthesia during surgery. The same polling found that respondents recognized the difference between a nurse anesthesiologist as a member of the nursing profession and a physician anesthesiologist as a medical doctor by a three-to-one margin.

That does not mean every patient understands every title perfectly. They do not. It does mean the blanket claim that “nurse anesthesiologist” is uniquely confusing deserves more scrutiny than it usually receives.

The Anesthesiologist Assistant Double Standard

The inconsistency becomes even more difficult to defend when we look at anesthesiologist assistants.

Some of the same voices that object to “nurse anesthesiologist” appear to have no problem with “Certified Anesthesiologist Assistant.” That matters because the word “anesthesiologist” is also right there in that title.

If the concern is that patients may see the word “anesthesiologist” and misunderstand the role, then that concern should apply consistently. It should apply to physician anesthesiologist, dentist anesthesiologist, nurse anesthesiologist, and anesthesiologist assistant. But in practice, the concern is not applied consistently.

“Physician” is treated as clarifying. “Dentist” is treated as clarifying. “Assistant” is treated as clarifying. Somehow, “nurse” is treated as uniquely confusing.

There is an additional irony here. Organized anesthesiology has also used “anesthetist” broadly enough to include anesthesiologist assistants, even though “anesthetist” has historically been closely associated with CRNAs. So the concern does not appear to be consistent overlap. The concern appears to depend on who benefits from the overlap.

When an anesthesiologist assistant uses a title containing “anesthesiologist,” the modifier “assistant” is accepted as clarifying. When a CRNA uses a title containing “anesthesiologist,” the modifier “nurse” is treated as confusing.

That is the double standard.

The Physician Associate Debate Shows the Same Pattern

This same pattern is visible outside anesthesia as well.

The PA profession has had its own title debate, with the American Academy of Physician Associates adopting “Physician Associate” as the official title of the profession. Supporters of the change argue that “associate” better reflects the modern PA role and avoids the outdated impression that PAs are merely technical assistants rather than licensed medical professionals with defined education, certification, and scope.

Organized medicine’s response has been predictable. The objection is again framed around patient confusion. The concern is that patients may see the word “physician” in “Physician Associate” and assume the person is a physician.

That concern is not unreasonable at its face value. Patients should absolutely know whether the person caring for them is a physician, PA, CRNA, nurse practitioner, dentist, resident physician, fellow, assistant, NAR, or any other member of the care team. Clear disclosure matters.

But the selective pattern is still hard to ignore. When “assistant” appears in a title, it is treated as clarifying. When “physician” appears in “physician anesthesiologist,” it is treated as clarifying. When “dentist” appears in “dentist anesthesiologist,” it is treated as clarifying. But when a profession seeks a title that better reflects its current role, whether “Physician Associate” for PAs or “nurse anesthesiologist” for CRNAs, the language is suddenly treated as dangerous, confusing, or misleading.

The controversy is not simply about whether patients understand words. It is about which words are allowed to elevate a profession’s perceived standing and which words are expected to keep that profession in a subordinate position.

If the standard is transparency, then apply it evenly. Require clear credentials. Require role disclosure. Require identification of licensure and scope. But do not pretend that “assistant” is inherently transparent while “associate” is inherently misleading, or that “physician anesthesiologist” is clear while “nurse anesthesiologist” is confusing.

That is not a consistent patient-protection standard. It is a status-protection standard.

This Is About Perceptual Rank

I understand why this debate is usually framed as patient protection. No serious health care professional wants patients confused or misled. Patients deserve accurate information about who is caring for them.

But if the true goal is patient understanding, then the solution should be more specificity, not less. The answer should be clearer disclosure of credentials, licensure, discipline, and role. It should not be selective suppression of titles used by one profession while similar constructions are accepted for another.

My concern is that this debate is often less about what patients understand and more about perceptual rank. Titles shape status. Status shapes assumptions. Assumptions shape power.

If one profession is allowed precise and prestigious language while another is pushed toward generic or historically subordinate language, the result is not transparency. It is hierarchy dressed up as transparency. That distinction matters. Health care teams do not function best when language is used to preserve rank. They function best when language accurately describes role, expertise, accountability, and contribution.

This is where the “proper recognition” framing can become misleading. Proper recognition should not mean preserving one profession’s prestige while minimizing another profession’s expertise. Proper recognition should mean accurate recognition. It should mean patients understand who is in the room, what that person is trained and licensed to do, and what role that person is performing in the patient’s care.

The “Mid-Level” Label Makes the Hierarchy Obvious

The same issue shows up in another term that many APRNs and PAs have rejected for years: “mid-level.”

On the surface, “mid-level provider” may sound like harmless administrative shorthand. It is not. It creates a rank before the conversation even begins. If someone is “mid-level,” then by implication someone else is “high-level,” and someone else must be below that. The hierarchy is built into the phrase.

That is why organizations such as the ANA, AANP and AANA have pushed back against terms like “mid-level provider,” “physician extender,” and “non-physician provider.” These terms do not simply describe a role. They define professionals in relation to physicians, rather than by their own education, licensure, certification, scope, and accountability.

This is relevant because some of the same institutions that object to certain professional titles in the name of patient clarity still use, tolerate, or benefit from language that is much less clear and far more hierarchical. “Mid-level” does not tell the patient whether someone is a CRNA, PA, NP, clinical nurse specialist, certified nurse-midwife, anesthesiologist assistant, or another licensed professional. It does not clarify training. It does not clarify scope. It simply ranks.

That is why the term belongs in this discussion. If the goal is transparency, then “mid-level” fails the test. It is not patient-centered language. It is status-centered language.

The better approach is to identify people by what they are: physician, CRNA, PA, nurse practitioner, dentist, pharmacist, anesthesiologist assistant, resident physician, NAR, or another specific professional role. That gives patients real information. Ranking people into high, middle, and implied lower levels does not.

No One Should Imply Credentials They Do Not Hold

None of this means that titles should be used carelessly. They should not.

A CRNA should not imply they are a physician. A physician should not imply they personally performed care they did not provide. A dentist should not imply they are an MD or DO physician. An anesthesiologist assistant should not imply independent licensure or independent anesthesia practice. A resident, fellow, assistant, NAR, or trainee should be clearly identified.

That part should be straightforward. The standard should be simple: say who you are, what your credentials are, what license or certification you hold, and what role you are performing in the patient’s care.

It is also fair to acknowledge that title laws, facility policies, and regulatory language vary by state and setting. Professionals should comply with applicable law and policy. But that is a separate question from whether the descriptor itself is inherently misleading. A term can be subject to local rules and still be descriptively accurate.

“Nurse anesthesiologist” does not hide the nursing identity. It states it directly. It does not erase the CRNA credential. It can be paired with it. It does not claim physician status. It distinguishes the professional pathway from physician anesthesiologist and dentist anesthesiologist while identifying the common clinical domain.

That is the transparency patients deserve. Not vague corporate language. Not selective title protection. Not professional branding masquerading as patient advocacy. Just clear, accurate, consistent disclosure.

The Better Standard

The better standard is not complicated.

Use “physician” for MDs and DOs. Use “CRNA” for CRNAs. Use “dentist” for DDS and DMD professionals. Use “doctor” when a doctorate has been earned, with appropriate disclosure of discipline and credentials. Use descriptive anesthesia titles that clarify the professional pathway, including physician anesthesiologist, nurse anesthesiologist, dentist anesthesiologist, and anesthesiologist assistant.

And avoid “provider” when a more precise title is available.

That approach protects patients without erasing anyone. It respects physicians without subordinating everyone else. It recognizes that language matters, but refuses to let language become a proxy war for hierarchy.

On the central point, I agree with the ACP: names in health care have ethical significance. But that ethical significance belongs to all of us.

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For hospitals and surgery centers, anesthesia staffing is no longer a departmental headache. It is a leadership issue.

Anesthesia is the access point for the surgical and procedural enterprise. When anesthesia coverage is stable, operating rooms run, endoscopy schedules move, obstetric services remain available, surgeons stay engaged, and patients receive care closer to home. When anesthesia coverage weakens, the effects are immediate and expensive: closed rooms, late starts, canceled cases, frustrated surgeons, delayed care, exposed obstetric services, and margin loss that affects other service lines.

Operating rooms are also among the most expensive assets in a hospital to leave idle. One JAMA Surgery analysis estimated operating room time at approximately $36 to $37 per minute in California hospitals.[1] That number will vary by facility and market, but the principle is the same everywhere. An unused room is not neutral. It is lost access, lost revenue, lost surgeon confidence, and lost community capacity.

The anesthesia shortage is real. But it is not the whole explanation.

A 2024 Anesthesiology review described a post-COVID anesthesia workforce supply-demand imbalance that disrupts procedural schedules, raises costs, and worsens burnout.[2] HRSA projects a shortage of 10,660 anesthesiology physicians by 2038, with non-metro communities expected to experience a much larger physician shortage than metro areas.[3] The CRNA workforce is under pressure as well. AANA has reported increased demand for CRNAs as hospitals and health systems work to keep ORs running, especially in rural and underserved settings, and notes that approximately 12% of CRNAs report plans to retire by 2027.[4] BLS also projects strong growth for APRN roles that include CRNAs, reflecting continued demand for this workforce.[5]

Still, workforce supply alone does not explain why some facilities are more stable than others.

The old arithmetic no longer works. Hospitals cannot simply post a job, add a sign-on bonus, and expect the market to solve the problem. New clinicians, including both CRNAs and physicians, are choosing practice settings based on workload, call burden, predictability, culture, compensation, professional respect, and whether they can actually use their training.

A sign-on may get clinicians in the door, but a practice environment built around 50-hour expectations, excessive call, unnecessary restrictions, and a culture that treats anesthesia professionals as interchangeable labor rather than highly trained clinical assets will send people back out of it. What clinicians used to consider “full time” 10 years ago is closer to 1.33 FTE in todays market.

“That’s how we’ve always done it here” is expensive

The most expensive phrase in anesthesia staffing may be, “That’s how we’ve always done it here.” It turns leadership decisions into inherited habits.

In anesthesia, this happens frequently. Supervision terminology, medical staff bylaws, payer billing rules, state scope-of-practice law, federal facility rules, liability concerns, and clinical privileges are often treated as if they are one thing.

They are not.

CMS “opt-out” is a good example. Opt-out does not define CRNA scope of practice. It does not determine what CRNAs are educated, licensed, credentialed, or privileged to do. Opt-out or not does not require one specific anesthesia staffing model.

Instead, opt-out addresses whether a Medicare-participating facility must meet a federal CRNA supervision condition as part of participation. The federal hospital Conditions of Participation state that, unless exempted through the state opt-out process, a CRNA must be supervised by the operating practitioner or by an immediately available Physician Anesthesiologist.[6,7] That language matters, but it is often misunderstood. In a non-opt-out state, the federal requirement does not, by itself, require Physician Anesthesiologist involvement, Physician Anesthesiologist medical direction, or Physician Anesthesiologist presence for every CRNA case. When the operating practitioner satisfies the supervision requirement, that does not transform the case into a medically directed anesthesia case or create case-level clinical control or liability for the CRNA’s anesthetic. It remains a facility participation requirement that is often mistaken for scope of practice, billing policy, medical direction, or local privileging authority.

When that confusion exists, the result is predictable. Facilities restrict qualified clinicians, increase coverage costs, reduce flexibility, and build expensive staffing models around perception rather than operational reality. Then they wonder why recruitment and retention are difficult.

Full utilization is not the same as unsafe independence

A sustainable anesthesia model uses every clinician to the full extent of education, licensure, credentialing, privileging, and demonstrated competence.

That does not mean every case should be assigned the same way. It means case assignment should be rational.

Patient acuity matters. Procedure complexity matters. Clinician training, experience, confidence, and demonstrated competence matter. Site resources matter. Escalation pathways matter.

Initials alone should not be the staffing model.

Physician Anesthesiologists bring valuable expertise in many settings. CRNAs also provide full-scope anesthesia care and are essential to coverage, especially in rural, community, and ambulatory environments. A mature anesthesia strategy recognizes both realities.

Collaboration does not have to mean supervision.

It can mean clear standards, mutual respect, consultation pathways, escalation triggers, and the right clinician with the right patient in the right location.

That is not political language. It is operational language.

The evidence does not support one rigid answer for every facility

Comparative evidence does not prove that one anesthesia staffing model is best for every patient, every case, or every facility.

A Cochrane review found variable results across available studies and concluded that the evidence was not strong enough to determine whether meaningful differences in care existed between anesthesia provider groups.[8] That does not mean staffing model does not matter. It means the question is more nuanced than many policy debates suggest.

The leadership question is simpler and more practical:

Which model can reliably deliver safe, compliant, timely, and financially sustainable procedural access for this community?

That answer may differ by hospital, service line, geography, payer mix, call burden, obstetric volume, surgical acuity, and available workforce.

A tertiary hospital with complex cardiac, transplant, neurosurgical, and high-acuity trauma services may need a different anesthesia structure than a rural critical access hospital, an endoscopy center, or a community facility trying to preserve obstetrics and emergency surgical access.

The problem is not variation.

The problem is pretending one inherited staffing model is the only acceptable model, even when it does not match the facility’s workforce reality, service line needs, or financial constraints.

Rural and community hospitals feel this first

For rural and community hospitals, this issue is not theoretical.

A Journal of Rural Health study found that 81.2% of rural counties had no Physician Anesthesiologist, 55.1% had no surgeon, and 58.1% had no CRNA.[9]

In those markets, anesthesia policy is not just an internal staffing issue. It may determine whether obstetrics, endoscopy, emergency surgery, pain procedures, and basic procedural care remain local.

When anesthesia coverage becomes unstable, the community does not simply lose an operating room. It may lose local maternity care. It may lose timely colonoscopy access. It may lose emergency surgical capability. It may lose the ability to keep routine care from becoming delayed, transferred, or fragmented.

That is why anesthesia staffing belongs on the leadership agenda.

Not just the anesthesia department agenda.

Not just the recruiter’s agenda.

Not just the medical staff committee agenda.

The leadership agenda.

Retention is strategy, not luck

Hospitals often put enormous effort into recruitment while underinvesting in retention.

That is backwards.

A national CRNA workforce survey found that greater autonomy in anesthesia delivery and higher compensation were associated with greater job satisfaction, while increased work hours reduced the probability of being very satisfied.[10] Broader APRN research has also linked autonomy, meaningful work, administrative support, salary, and better practice environments with job satisfaction and retention.[11,12]

In plain terms, people stay where the practice environment is functional.

They stay where workload is realistic. They stay where call burden is shared fairly. They stay where scheduling is predictable. They stay where their professional judgment is respected. They stay where leadership understands that unnecessary restrictions are not harmless. They affect morale, recruitment, retention, and cost.

A sign-on bonus can rent attention. It cannot compensate long-term for a poor culture, excessive call, lack of respect, or exclusion from decisions about the work itself.

That last point matters. Too often, anesthesia workforce strategy is built outside the anesthesia workforce. Administrators, consultants, medical staff leaders, and finance teams may debate models without directly asking the clinicians they hope to recruit and retain what would make them join, stay, and build stability.

That is a leadership failure.

Better questions lead to better models

Hospital and surgery center leaders should start by asking better questions.

1. Where is procedural demand highest by location, acuity, day, and time?

2. Do you need more anesthesia providers or better block utilization?

3. Which rooms are being closed because of anesthesia coverage?

4. What is the first-case start performance?

5. How often are cases canceled or delayed because of staffing?

6. What is the subsidy per covered site?

7. What is the true cost of call coverage?

8. How long does it take to recruit one CRNA or Physician Anesthesiologist?

9. What is the turnover rate after you recruit them?

10. What restrictions are legally required, and which are simply cultural preferences?

11. Are we staffing around “this is the way we have always done it here,” or around actual demand, utilization, acuity, and available workforce?

Those questions move the conversation from ideology to operations.

They also help leaders separate what is required from what is preferred, what is evidence-based from what is habitual, and what protects patients from what simply protects tradition.

The leadership responsibility

Hospitals and surgery centers cannot bonus their way out of a poor practice environment.

They need anesthesia models that protect access, respect professional capability, distribute workload realistically, and align policy with evidence. They need to stop treating anesthesia staffing as a narrow departmental problem and start treating it as a core access, finance, quality, and community service issue.

The facilities that succeed will not be the ones that simply pay the highest temporary rate. They will be the ones that build practice environments where clinicians want to work, where patients can access care, where surgical and procedural platforms remain reliable, and where staffing models are designed around reality rather than inherited assumptions.

That is why anesthesia staffing is not only an anesthesia problem.

It is a hospital leadership problem.

References

1. Childers CP, Maggard-Gibbons M. Understanding Costs of Care in the Operating Room. JAMA Surgery. 2018;153(4):e176233. link

2. Abouleish AE, Pomerantz P, Peterson MD, et al. Closing the Chasm: Understanding and Addressing the Anesthesia Workforce Supply and Demand Imbalance. Anesthesiology. 2024. doi:10.1097/ALN.0000000000005052. link

3. Health Resources and Services Administration. Health Workforce Projections. National Center for Health Workforce Analysis. link

4. American Association of Nurse Anesthesiology. 2025 Job Market Outlook for CRNAs. link

5. U.S. Bureau of Labor Statistics. APRN Occupational Outlook Handbook. link

6. Electronic Code of Federal Regulations. 42 CFR 482.52: Condition of participation: Anesthesia services. link

7. Centers for Medicare & Medicaid Services. State Operations Manual, Appendix A: Survey Protocol, Regulations and Interpretive Guidelines for Hospitals. link

8. Lewis SR, Nicholson A, Smith AF, Alderson P. Physician anaesthetists versus non-physician providers of anaesthesia for surgical patients. Cochrane Database of Systematic Reviews. 2014;CD010357. link

9. Cohen C, Baird M, Koirola N, et al. The Surgical and Anesthesia Workforce and Provision of Surgical Services in Rural Communities. The Journal of Rural Health. 2021. link

10. Negrusa S, Hogan P, Jordan L, et al. Work patterns, socio-demographic characteristics and job satisfaction of the CRNA workforce: Findings from the 2019 AANA survey of CRNAs. Nursing Outlook. 2021;69(3):370-382. link

11. Han RM, Carter P, Champion JD. Relationships among factors affecting advanced practice registered nurses’ job satisfaction and intent to leave: A systematic review. Journal of the American Association of Nurse Practitioners. 2018;30(2):101-113. link

12. Poghosyan L, Kueakomoldej S, Liu J, Martsolf G. Advanced practice nurse work environments and job satisfaction and intent to leave. Journal of Advanced Nursing. 2022;78(8):2460-2471. link

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For every nurse anesthesia resident running on caffeine, tape, labels, and the quiet fear.

This one is for the clinical days, the questionable technique, and the moments where all you hear is… “Who taught you that?!?” From every preceptor

Brought to you by us at NUDNAP!

Hit play, laugh a little, every CRNA has absolutely lived this.

#narlife #nurseanesthesia #NAR #CRNALife #whotaughtyouthat #clinicalsurvival

Every anesthesia professional knows how this usually goes. You read the compensation, the call schedule, the PTO, the sign-on, maybe the tail language if you are lucky, and then you hit the restrictive-covenant section and tell yourself you will come back to it later. That is how people end up boxed out of their own hospital, their own town, or their own income stream. Tracy Young, MSNA, MBA, CRNA, co-founder and COO of Essential Anesthesia Management, recently captured the anesthesia version of the problem by describing non-competes as a moat around lucrative contracts. That framing is blunt, but in this market it is often closer to the truth than people want to admit.

The reason this deserves real attention is that the knowledge gap is not theoretical. In the Meseroll et al. survey published in AANA Journal, the chart on page 5 showed that 30.2% of practicing CRNA respondents reported having a non-compete and 9.1% did not even know whether they had one. The same study found low overall knowledge, and independent CRNAs reported more experience declining jobs, changing jobs, and losing employment because of these clauses.

And anesthesia is uniquely vulnerable to this problem because our employment relationships are tied so tightly to site contracts. Groups merge. Hospitals rebid. Subsidy disputes happen. AMCs replace legacy groups. Hospitals try to hire the same clinicians under a new arrangement. Meseroll’s paper was already warning in 2015 that many CRNAs only learn what their contract really means during an acquisition, merger, or contract turnover. That is still exactly how these fights play out.

Where these clauses came from

Restrictive covenants are old. The roots go back to English common law, including Dyer’s Case in 1414 and Mitchel v. Reynolds in 1711, which shaped the modern “rule of reasonableness.” That basic framework still drives most litigation now: the employer usually has to show consideration, a legitimate business interest, and reasonable limits on activity, time, and geography. An anesthesia-specific legal review from Anesthesia Business Consultants described the framework the same way years ago, and that remains the basic playbook today.

How that doctrine shows up in an anesthesia contract today

That history matters because the modern anesthesia non-compete usually is not about a CRNA opening a competing office down the street and stealing a referral base. In anesthesia, the real asset is often the staffed site itself: the hospital contract, the ASC relationship, the call structure, the coverage model, and the workforce attached to that site. So when a group puts a non-compete into a CRNA or physician anesthesiologist contract, it is often trying to protect control over that business relationship, not just protect some classic trade secret.

That is why these clauses tend to become a live issue during acquisitions, mergers, rebids, subsidy disputes, and contract turnover. The old doctrine came from a broad restraint-of-trade framework, but in anesthesia today it often gets used as a site-control tool. It can be used to try to stop a CRNA from staying at the same hospital after the old group loses the contract, to make it harder for a hospital to hire clinicians directly, or to give the outgoing group leverage when a replacement company wants to keep the same workforce in place.

That is also why anesthesia professionals should not read these clauses like generic boilerplate. In our world, they are often tied to who controls coverage, who keeps the revenue stream, and who gets to keep staffing the rooms when a contract changes hands. Once you understand that, the language in the contract makes a lot more sense, and the risk becomes much easier to spot before it turns into a lawsuit.

Why employers argue these clauses protect legitimate business interests

There is also substantial and often invisible cost behind an anesthesia contract that most frontline clinicians never see. Before a group ever staffs the first room, it may have already spent significant nonclinical time and money preparing to win and launch that contract. That can include recruiter fees, advertising, leadership hours spent planning and building the bid, unpaid administrative time, legal review and negotiation, compliance preparation, credentialing and onboarding, startup scheduling and call-design work, and the ongoing expense of managing the relationship once the contract is live.

From the company’s side, those are exactly the kinds of investments it will point to when arguing that it has a legitimate business interest worth protecting. And to be fair, that argument is not made up out of thin air. In anesthesia, the business interest often is not just abstract goodwill. It is the real cost of bidding on, starting, stabilizing, retaining, and managing the contract itself.

That still does not mean every non-compete should hold up. It only means the employer may have a stronger argument than if it were simply trying to block ordinary job movement for no real reason. The court still has to decide whether the restriction is reasonable in scope, geography, and duration, and in healthcare it still has to weigh hardship to the clinician and the effect on access to care.

Healthcare adds another layer that ordinary business disputes do not always have. Courts are often asked to balance the employer’s business interest against clinician hardship and the public’s interest in access to care. Arizona’s Supreme Court said exactly that in Valley Medical Specialists v. Farber, holding the covenant there unenforceable because public policy concerns outweighed the practice’s protectable interests.

Non-compete, non-solicit, and confidentiality are not the same thing

A non-compete is the clause that tells you where you cannot work, or for whom you cannot work, after you leave. A non-solicit is different. It usually tries to stop you from recruiting the former employer’s employees, patients, or clients. A confidentiality provision is different again. It governs what information you cannot use or disclose after you leave. Meseroll et al. correctly treated all of them as part of the broader restrictive-covenant family. Arizona CRNA-oriented contract guidance explains the same distinction in practical terms.

Where this gets messy in anesthesia is the overlap. When the “client” is a hospital and the workforce is the only realistic way to keep rooms open, a non-solicit or no-hire clause can do the work of a non-compete without ever using the label. That is one reason the St. Joseph’s/NAPA litigation mattered so much. The hospital challenged a two-year non-solicitation clause in the services agreement that barred either side from inducing the other’s employees to leave; the court allowed antitrust claims to proceed, NAPA’s TRO request was denied, and the cases later settled. In other words, the fight was not just about clinician employment contracts. It was also about the service-agreement language sitting above them.

That is also why people get burned when they think, “The non-compete is probably void, so I’m fine.” Maybe. Maybe not. If you stay quietly, that is one thing. If you start coordinating a group move, connecting coworkers to the incoming employer, arranging interviews, or acting as the bridge for a mass departure, you may have moved the fight from a non-compete theory to a non-solicit or interference theory. And the answer is not the same in every state. California is strongly hostile to post-employment restraints and AMN Healthcare applied that policy to an employee nonsolicit, but New Mexico expressly preserves one-year nonsolicits as to patients and employees, and Oklahoma still lets a former employee work in the same business while prohibiting direct solicitation of established customers.

Confidentiality is the other trap people underestimate. Not every staffing detail or workflow is automatically a trade secret just because the employer says so. But both trade-secret law and contract law do protect genuinely secret business information when the owner took reasonable steps to keep it secret and the information has independent value. AMN Healthcare shows how quickly a departure fight can expand into allegations about confidential information and trade secrets, and the federal trade-secret definition is broad enough to include financial, technical, and business information when those requirements are met. That is why forwarding internal schedules, compensation grids, staffing models, internal emails, surgeon-volume data, or site-specific operational playbooks to the incoming group can create a very different kind of exposure than simply taking a new job.

And I would never assume the incoming group or facility will clean that up for you just because somebody casually said, “We’ll handle it.” In Beaumont, the rival employer allegedly agreed to cover legal fees, damages, and expenses, and the injunction still issued anyway. A promise to “cover the fallout” is not the same thing as making the problem disappear.

A single-facility restriction and a geographic restriction are not the same risk

A site-based non-compete usually says you cannot work at Hospital X, or at any facility serviced by the former group. A geographic non-compete says you cannot work within a defined radius of one or more covered sites. On paper, the site-based clause sounds narrower. In the real world, either one can be brutal.

If you live in a one-hospital town, a “single facility” restriction can function like a total local ban. If you live in a metro area and float between multiple sites, the geographic version can be worse, especially if the radius is measured from every location you touched. In Beaumont, the trial court found a three-year restriction tied to a 20-mile radius reasonable. That is not a minor inconvenience if your practice footprint is already concentrated around one health system.

And a site-based clause is not automatically safer just because it avoids a mileage number. In Louisiana, an anesthesiologist’s non-compete that barred practice at “any health care facility regularly serviced” by the employer was held unenforceable because the contract failed to specify the geography required by statute. So yes, a vague facility clause can fail. But that is not a strategy. That is a lawsuit.

The biggest myth in anesthesia: “If the group loses the contract, the non-compete dies”

Sometimes that argument works. Sometimes it absolutely does not.

This is the question anesthesia clinicians get wrong over and over. They assume that if the old group loses or terminates the hospital contract, the old “you can’t work here anymore” language should collapse with it. In some jurisdictions and fact patterns, courts do become skeptical once the employer no longer has the underlying site relationship. But Beaumont is the cautionary example of why no one should bet their mortgage on that assumption.

In Beaumont, Anesthesia Associates gave written notice in March 2025 that it would terminate its CHRISTUS contract effective August 1, 2025. That same day, four CRNAs began working at CHRISTUS facilities for a competitor. Anesthesia Associates filed suit on August 1, 2025, obtained a TRO that day, later obtained a second temporary injunction on September 12, 2025, and on April 16, 2026 the Texas Ninth Court of Appeals affirmed the temporary injunction. The court accepted the employer’s argument that it still had protectable goodwill and business interests even after the site contract ended. In plain English, the covenant outlived the hospital contract.

There is a counterexample, and it matters. In the Fort Sanders litigation in Tennessee, the anesthesia group sought a massive subsidy increase, gave notice it would stop providing services, and then sent cease-and-desist threats when the hospitals moved to keep clinicians at the sites. The Tennessee Court of Appeals affirmed the trial court’s refusal to enforce the covenants, with the opinion discussing the threshold requirement of a legitimate business interest and the public-interest consequences of losing anesthesia coverage. That is a real win for clinician mobility and patient access. It is also proof that these cases are intensely fact-specific.

That is the real takeaway. Public interest can matter. Contract loss can matter. Lack of a legitimate business interest can matter. But none of those things automatically save you. Sometimes the judge sees workforce protection as anti-competitive. Sometimes the judge sees it as protection of goodwill and operational investment. That uncertainty is exactly why these clauses are dangerous.

In states that limit or ban non-competes, the old group may still have leverage

This is where legal doctrine and real life diverge.

In a state that truly voids the non-compete itself, the outgoing group usually has a much weaker argument that it can simply block you from staying at the same facility after a takeover. But weaker is not the same thing as powerless. The leverage often shifts to nonsolicits, confidentiality, trade-secret claims, no-hire language in the hospital-services agreement, repayment provisions, liquidated-damages clauses, and plain old litigation friction.

Sometimes the most important restrictive covenant is not even in your employment contract. It is in the agreement between the hospital and the group. That was one of the core issues in St. Joseph’s v. NAPA, where the challenged non-solicitation clause sat in the services agreement itself and was alleged to foreclose competitive alternatives for keeping anesthesia providers at the hospital.

Even void clauses can still create enough friction that legislatures have started targeting the conduct itself. California is the clearest example. Section 16600 voids employment non-competes broadly, and Section 16600.1 makes it unlawful to include a non-compete clause that does not fit a statutory exception. Legislatures do not write statutes like that unless employers have been trying to use unenforceable language as leverage anyway.

The state-law patchwork anesthesia professionals actually need to know

This is not a 50-state survey, and anyone pretending it is can only do it by oversimplifying. But there are a few states anesthesia professionals should know cold.

California remains the cleanest broad anti-non-compete example. Section 16600 says contracts restraining lawful work are void to that extent and must be read broadly in the employment setting, and Section 16600.1 makes it unlawful to include a non-compete clause that does not satisfy a statutory exception. California courts have also applied that policy to employee nonsolicitation provisions, as in AMN Healthcare.

Rhode Island deserves special attention because it now has protection that matters directly to CRNAs. Katz Banks’ March 2026 nationwide update notes Rhode Island’s general wage-threshold restriction on non-competes, but the more important point for anesthesia is Rhode Island’s APRN-specific statute. Rhode Island defines APRNs to include CRNAs, and its 2024 APRN law says contract restrictions on an APRN’s right to practice are void as to that restriction. The statute specifically voids geographic practice restrictions and limits on providing care to, or soliciting a professional relationship with, current patients, while leaving the rest of the contract intact.

New Mexico is one of the most anesthesia-specific statutes in the country because it expressly includes CRNAs in the definition of “health care practitioner.” It makes provider non-competes unenforceable upon termination and voids out-of-state law and forum provisions for New Mexico clinical services. But it also shows exactly how employers preserve leverage when the formal non-compete dies: the statute expressly preserves repayment obligations, confidentiality and trade-secret provisions, one-year nonsolicits as to patients and employees, and reasonable liquidated-damages clauses.

Maryland took a threshold approach. Licensed direct-patient-care healthcare workers at $350,000 or less cannot be bound by these provisions; above that threshold, the cap is one year and 10 miles from the primary place of employment, for agreements executed on or after July 1, 2025. That matches the 2026 Maryland practitioner summaries circulating online, but the statute is the source that matters.

Texas now limits non-competes for nursing, dentistry, and physician assistants in agreements entered into or renewed on or after September 1, 2025. For nursing, the covenant must have a buyout no greater than annual salary and wages, last no more than one year, stay within five miles of the primary practice location, and be clearly stated in writing. Older covenants still live under prior law, which is precisely why Beaumont still matters.

Arizona is not a ban state. It is a reasonableness-and-public-interest state. Farber is still the landmark Arizona case on strict scrutiny of healthcare restrictive covenants, and Arizona CRNA-focused contract guidance still emphasizes the same practical factors: geography, duration, legitimate business interest, and the public’s need for access to care.

North Dakota is still broadly hostile to non-competes. Oklahoma shows why clinicians have to read carefully even in states that are hostile to full non-competes: the former employee may work in the same or similar business, but direct solicitation of established customers can still be barred. “Ban state” and “no post-employment risk” are not the same sentence.

And the larger trend is still a patchwork. Katz Banks’ March 2026 update notes that the successful 2025 legislative changes were concentrated heavily in healthcare-worker restrictions rather than sweeping across every industry. That is exactly why anesthesia professionals cannot rely on general workplace chatter or old social-media advice. The answer is still state-specific and profession-specific.

The real cost is not just whether you win. It is when you are allowed to work.

This is the part too many clinicians miss. You do not need to lose the final case to lose a huge amount of money.

Non-compete litigation usually starts with emergency relief, not final trial. The outgoing employer files for a TRO or temporary injunction and tries to take you off the schedule while the merits fight is still in front of the court. In Beaumont, that is exactly what happened. Anesthesia Associates filed on August 1, 2025 and got a TRO the same day. The trial court entered a first temporary injunction on August 20, effective September 4. The appellate court reversed that first injunction as void on September 4 because the order failed to set the full case for trial on the merits. Then the employer came back, obtained a second temporary injunction on September 12 with a June 8, 2026 merits setting, and the appellate court affirmed on April 16, 2026. Even the clinicians’ procedural win did not end the fight.

That is roughly eight and a half months of active injunction litigation before you even get to the merits setting that was placed on the calendar in the second injunction order. And during that time, the whole point of the employer’s motion is to stop you from working where you were trying to stay.

The hard-dollar exposure can get ugly fast. In Beaumont, the federal order states that before and after suit the rival employer offered $30,000 for each CRNA, but Anesthesia Associates refused and allegedly demanded $400,000 per CRNA to drop its injunctive demand. Using BLS’s May 2023 Texas CRNA annual wage estimate of $216,280 as a conservative benchmark, eight and a half months out of the local market is roughly $153,000 in gross income disruption per CRNA before you even start talking about commuting, relocation, or your own attorney’s fees. And that is before considering the contract-defined $30,000 liquidated-damages exposure.

At the institutional level, the St. Joseph’s complaint against NAPA alleged the outgoing group initially demanded more than one and a half times the annual salary of each anesthesia provider to waive the non-competes, a number the hospital said exceeded $20 million, before later describing a “discount” to $12 million. Those are complaint allegations, not final findings, but they illustrate the leverage these provisions can create during anesthesia contract turnover.

The fee numbers themselves are often not cleanly available in public dockets. But the structure of these cases tells the story anyway: TROs, temporary-injunction hearings, emergency appeals, multiple filings, and sometimes parallel state and federal litigation can all hit long before there is any final decision. The cost is not just legal fees. It is lost work, lost negotiating leverage, and months of uncertainty while somebody else argues over whether you can stay in the room.

The FTC did try to kill non-competes nationally. That did not stick.

A lot of clinicians still talk as if the FTC ban solved this. It did not.

The FTC issued a final non-compete rule in 2024, but it never became an operative nationwide protection. The FTC now says the rule is not in effect and not enforceable. The Federal Register explains why: one court set the rule aside, the FTC later voted to dismiss its appeals and accede to vacatur, and the Commission then removed the Non-Compete Rule from 16 CFR part 910 in February 2026. State law remains the battlefield.

My view

There are legitimate employer interests in some cases. Real trade secrets exist. Real confidential strategy exists. Real business goodwill exists.

But in anesthesia, these clauses are often doing something much more practical and much less noble: controlling labor during contract turnover. They are frequently less about protecting a secret sauce and more about deciding who gets to keep staffing the site when money, subsidies, or market share change hands. Meseroll’s work showed the profession has long underappreciated the risk, and the modern cases show the risk has only become more operationally important.

What I would tell any CRNA before signing, or before a contract turnover

Read the restrictive-covenant section before you negotiate almost anything else.

Ask exactly what triggers it. Is it resignation only, or termination without cause too? Does it survive if the group loses the contract? Is it tied to one named facility, every facility you touched, or a radius around all of them? Is there a real buyout, or just liquidated damages plus the employer’s separate right to seek an injunction? What nonsolicit, confidentiality, no-hire, repayment, venue, and attorney-fee language survives even if the non-compete itself is weak? And what does your state say for CRNAs, APRNs, nurses, or direct-patient-care clinicians specifically, not just for physicians in general?

And if a site is about to turn over, keep your mouth disciplined. Deciding to stay is one thing. Recruiting coworkers, sharing internal documents, or functioning as the relay point between the outgoing staff and the incoming group is where an employment move can mutate into a solicitation, confidentiality, or trade-secret fight.

This is general education, not legal advice. If you are signing one of these agreements or a hospital contract is turning over, get a healthcare employment attorney in your state before you give notice or start coordinating anything.

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Share No Gaslighting - Just Gas

Every year we get the same question from applicants. “What do you think about the US News rankings?”

And every year we give the same answer: they should not be driving your decision.

That is not because rankings are always bad. It is because this one is so methodologically weak that it should not be treated as meaningful.

We did not just assume that. We looked into it, emailed them, asked how it works, and got the answer in writing. Once you understand what is actually behind these rankings, it becomes very hard to take them seriously.

It all comes down to one question

The entire ranking is built on one survey question. One.

Program administrators and deans are given a list of programs and asked to rate them from 1 to 5 based on “academic quality.” That’s it.

No objective outcomes are used. No board pass rates. No attrition. No clinical performance data. No validation that the person scoring a program has any meaningful firsthand knowledge of it.

That alone should make applicants pause.

In anesthesia education, quality is measurable

That is what makes this methodology especially hard to defend in anesthesia education. Training quality here is not some abstract concept that cannot be measured. It is measurable in ways that actually matter:

• Case volume

• Case complexity

• Regional experience

• Clinical autonomy and practice model exposure

• Board pass rates

• Attrition

• Graduate preparedness

• Resident satisfaction

None of those are included.

So what exactly is being ranked?

Not training. Not outcomes. Not competency.

What is being ranked is not training quality. It is a mix of name recognition, institutional prestige, secondhand impressions, and assumption.

Name recognition is not the same thing as quality

At best, what you are looking at is a survey of perception, and even that gives it too much credit.

A true reputational survey would at least assume the people answering have meaningful knowledge of the programs they are rating. Here, there is no mechanism that ensures that.

The only people being surveyed are program administrators and deans. Not current residents. Not recent graduates. Not employers. Not faculty deeply involved in day-to-day training. Not clinical coordinators.

That creates an obvious problem.

How is one administrator supposed to meaningfully rate dozens, let alone more than 150, programs across the country?

They are not reviewing clinical logs. They are not observing those programs in practice. They are not sitting in those classrooms. In many cases, they may have had little or no meaningful contact with the program they are scoring.

So what are they actually rating?

Usually some combination of name recognition, institutional prestige, secondhand impressions, partial familiarity, and assumptions. That is not the same thing as informed judgment.

The incentives are worse than people want to admit

This is where the whole framework starts to fall apart.

If there is no requirement for direct knowledge, and the process is fully subjective, then the incentive structure matters.

And the incentive structure here is not neutral.

If rankings influence perception, and perception influences applications, and applications influence program strength, then programs have a built-in incentive to score competitors lower.

Nothing in the methodology prevents that. Nothing in the methodology adjusts for it. Nothing in the methodology even meaningfully addresses it.

Look at the middle of the rankings. Many programs are sitting around 2.7 out of 5.

Think about what that implies.

Are we really supposed to believe the average CRNA program in the United States is barely above marginal?

That does not pass a basic sanity check.

So you have to ask the obvious question: why are programs being scored as 1s and 2s by people who may know little or nothing about them? Is that really a reflection of quality, or simply the predictable distortion of a subjective ranking system?

That is not an accusation against any one program. It is simply the predictable result of the way this system is built.

This is not just a CRNA program problem

Entire academic disciplines have started walking away from US News rankings for the same basic reason: flawed methodology, overreliance on reputation, and results that do not reflect actual educational quality.

But in our space, people still give these rankings more weight than they deserve.

And that matters, because some universities do not treat these rankings as meaningless background noise. They promote them prominently on their websites, use them in recruitment messaging, and in some cases put real pressure on faculty or program leadership to improve them. That would make sense if the ranking reflected meaningful educational quality. The problem is that it does not.

Why it still carries weight

Because they simplify a complicated decision. They give applicants a shortcut. They give programs a marketing talking point. They create the appearance of precision and hierarchy, even when neither is grounded in meaningful evidence.

What applicants should look at instead

If you are serious about choosing a program, ask questions that actually measure training quality.

What kinds of cases are you doing, and how many? What does the clinical training environment actually look like? Are you being trained to think independently, or are you spending your education in a tightly controlled model? What are the board pass rates? What is the attrition rate?

What do recent graduates say when you talk to them without the program filtering that conversation?

That is how you evaluate the quality of a program.

Not by a number generated from a single subjective survey question answered by people who may have never meaningfully seen the programs they are rating.

Final thought

Once you understand how these rankings are actually built, they stop looking impressive.

They are not a meaningful measure of training quality. They are a subjective opinion survey presented as if it were objective.

Applicants deserve better than that.

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If you want to learn more about the rankings:

Watch Malcom Gladwell Revisionist History Origins: College Rankings Scandal | Malcolm Gladwell

Listen to this podcast “Lord of the Rankings” with Revisionist History

Read MacIver Institute Another Academic Data Manipulation Scandal: US News Rankings: Garbage In, Garbage Out

Read The Atlantic Your Annual Reminder to Ignore the U.S. News & World Report College Ranking

Read Forbes College Rankings Mislead Students. Universities Should Abandon Them.

Read the New York Times Despite Years of Criticism, the U.S. News College Rankings Live On

Read the Cincinnati inquirer U.S. News college rankings are out. Why critics say they shouldn’t be trusted

Read Inside Higher Ed Why New ‘U.S. News’ Rankings Are Flawed

The “Kids These Days” Script

Spend enough time around clinical training and you will eventually hear the same speech dressed up in different clothes: this group is softer, too used to comfort, too dependent on technology, and nowhere near as tough as we were. Somewhere in the story comes the old folklore about walking uphill both ways to clinical in the freezing cold with no shoes, followed by the same conclusion people have been drawing for centuries: the next generation just does not have what we had.

People talk like it is a modern crisis. It is not.

We have been running this script for a very long time. Aristotle complained that young people had not yet been humbled by life and thought they knew everything. Horace said the next generation wasted money and discipline. In 1816, The Times of London warned parents about the immoral new dance called the waltz. In 1858, Scientific American worried chess was rotting minds. In 1926, religious writers were convinced movies were corrupting youth. In 2001, the story became short attention spans and entertainment culture. Different century, same diagnosis: the kids are ruining everything.

One of the most honest observations on all of this showed up in a newspaper in 1934:

That gets a lot closer to the truth.

History does not prove every critique of trainees is wrong. It does remind us how easy it is to mistake change for decline, and how often nostalgia gets dressed up as wisdom.

After enough years in clinical practice and education, I have come to think that every generation confuses its own scars with standards.

What This Looks Like in NAR Training

Talk to enough people and you will hear the modern version: today’s nurse anesthesia residents, or NARs, are softer, too dependent on technology, less resilient, and too concerned with policies and feedback. For some people, the mere fact that an NAR talks about burnout or mental health is enough to label them weak.

Sometimes there is a grain of truth. Every generation has weak spots, and accountability still matters.

That matters because the easy story about softness misses the actual training environment. Today’s NARs are learning in operating rooms that are more technologically dense, more tightly documented, and less forgiving of drift than the ones many of us trained in. Their patients are older and sicker. The expectations are layered. A modern NAR may start the day with a frail patient, an ultrasound-guided procedure, an EHR full of clicks, and a room already behind before the first induction even begins. They are expected to think clinically, move efficiently, absorb feedback, master equipment, document everything, and do it in systems already strained by throughput pressure, staffing problems, and administrative drag.

That is why clearer expectations are not a sign of weakness and feedback is not fragility. Most of the time, they are signs of serious learners trying to calibrate in a complicated environment. Talking openly about burnout is not a character defect either. It is what honesty sounds like in a profession that asks a lot.

What Has Not Changed

None of this means we drop standards. Patients deserve clinicians who are prepared, decisive, and safe. Training still requires repetition, progressive responsibility, honest evaluation, and the ability to hear hard things without falling apart. The bar stays high. What should not survive is the habit of confusing rigor with opacity, inconsistency, or ritualized suffering.

The danger in every generation is thinking that hardship itself was the lesson. It was not. The lesson was becoming competent enough to take good care of patients. That is still the job. History matters here only because it reminds us how easy it is to mistake change for decline and nostalgia for wisdom. Meet NARs where they are, hold them to a high standard, and make sure what we are protecting is excellence, not nostalgia.

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Part 1 focused on how admissions decisions are made. This discussion shifts to what happens after that decision. Earning an interview or even an acceptance is one challenge. Sustaining performance inside a nurse anesthesiology program is another entirely. Strong applicants are sometimes unprepared for the intensity of training, and that gap in expectation can become consequential very quickly.

“School / Life Balance”: A Necessary Reality Check

This is the part that makes some applicants uncomfortable and every cycle, we hear some version of this:

“I’m looking for a program that values school/life balance.”

There is PTO, there are occasionally short days, and there is accommodation for major life events. However, interpreting those realities as evidence of lifestyle flexibility misunderstands the structure of doctoral clinical training.

This is doctoral clinical training. It exceeds traditional full-time employment in cognitive demand, responsibility, and time commitment, and it is immersive by design.

When you applied, you applied to a doctoral-level clinical training program. That means:

• Full academic load

• High-stakes examinations

• Dense pharmacology and physiology

• Clinical days that start before sunrise

• Cases that demand cognitive precision

• Studying after clinical

• Studying before clinical

• Studying on weekends

There are seasons where the volume feels relentless, like drinking water from a firehose. The critical point is that the hose does not stop. If you fall behind, the curriculum does not pause. The next exam still comes, the next clinical day still arrives, and the next set of competencies still must be met.

The intensity exists because the stakes are high. The operating room does not slow down when a provider feels overwhelmed. Training reflects that reality.

This is where the “balance” myth becomes dangerous. If you attempt to give everything to everyone all the time while in this program, something gives. And when what gives is academic performance, remediation and dismissal become real possibilities.

When you invest this much money, time, reputation, and emotional capital into a program, it must become a defined priority. You would not make the largest investment of your life and then ignore its maintenance. The same logic applies here.

For applicants, this is a reality check. For families, it becomes a reality once the program begins.

You will miss events, decline invitations, and spend holidays studying. There will be stretches where you feel like a ghost.

Those conversations must happen before you start.

Spouses, partners, parents, and close friends need to understand the intensity. They need to know this is temporary but consuming. They need to understand that for a defined period of time, this program has to take precedence.

Alignment before matriculation prevents crisis during matriculation.

Programs are structured around fixed academic and clinical standards. Nurse anesthesia residents most often struggle when competing priorities fracture focus.

You cannot train for one of the most cognitively demanding advanced practice nursing specialties and live as if nothing changed. If you are accepted, the opportunity is extraordinary. Treat it accordingly.

For a defined window of time, it takes what it takes.

“What Are You Going to Do to Ensure My Success?”

This question appears more often in interviews and emails than people realize. It deserves a direct answer.

Faculty will teach. Preceptors will coach. Programs will provide structure, evaluation, feedback, and resources. We will facilitate your learning.

But in a doctoral clinical program, no one can execute the most important part for you: ownership.

This is professional formation. It is not undergraduate education. It is not orientation to a new ICU job. It is doctoral-level clinical training. Faculty are facilitators and evaluators. You are responsible for execution.

The stronger version of that question sounds different.

“Here is how I learn best. Here is how I plan to study, seek feedback, and close gaps early. How can your program help me execute that plan?”

That framing shifts accountability where it belongs.

At this level, successful residents behave like adult learners. They are self-directed. They are internally motivated. They identify weaknesses early and close them aggressively. They seek feedback without defensiveness. They adjust.

Programs create the environment.

Residents create the plan.

When someone struggles, it is rarely because the program did not provide resources. It is usually because the resident did not take full ownership of using them.

Know How You Learn or You Will Waste Time “Studying”

There is a practical piece that many residents underestimate.

Time is not the problem. Inefficient learning is.

If you do not have a defined system, you default to whatever study method is loudest around you. That may not be what works for you.

Start simple. Use something like VARK (visual, auditory, reading/writing, kinesthetic) as a framework. Not as a label. As a tool.

If you are primarily visual, build diagrams, physiology flow maps, concept maps, drug comparison grids, and crisis algorithms.

If you are auditory, teach concepts out loud. Record yourself explaining physiology. Rehearse rapid question-and-answer. Practice verbalizing anesthesia plans.

If you are reading and writing oriented, convert notes into structured outlines and one-page summaries. Then close the document and test yourself repeatedly.

If you are kinesthetic, rehearse case plans. Walk through airway setups. Simulate crisis steps intentionally. Move through induction and emergence scenarios mentally and physically.

Then do the most important step.

Cross-check your thinking early.

Ask peers, upperclassmen, or advisors whether your preparation aligns with exam expectations and clinical performance standards. Adjust quickly. Do not wait for a failing grade to recalibrate.

Programs will not hand-hold.

But they will engage deeply with a learner who demonstrates ownership, strategy, and the willingness to adapt.

At this level, effort alone is not enough. Strategy matters.

The Comeback > The Setback

Here is something many applicants do not realize.

If you applied, received constructive guidance, and returned having addressed those recommendations directly, that changes the tone of the committee discussion. Retaking a course and earning an A. Moving to a higher-acuity unit. Completing graduate-level sciences. Strengthening leadership involvement. Preparing deliberately for the interview.

Those actions demonstrate coachability, discipline, and resilience under evaluation. Those traits translate directly into clinical training. When measurable growth is evident between cycles, the committee conversation changes. You are no longer just another applicant file. You are someone who demonstrated the ability to assess performance, correct deficits, and return stronger.

There is real psychology behind why that matters.

Carol Dweck’s work on growth mindset emphasizes that ability is not fixed. It is developed through effort, feedback, and correction. Angela Duckworth’s research on grit highlights sustained effort over time as a predictor of long-term achievement.

A comeback demonstrates both.

You received feedback without defensiveness.
You identified a deficit.
You built a plan.
You executed the plan.
You returned stronger.

That is not simply ‘reapplication’. It shows us professional maturation under evaluation.

Those are the traits that translate to clinical training and ultimately to the operating room.

The quote below captures it perfectly.

Admissions committees respect the comeback because it demonstrates growth. We do not always remember the applicants who were perfect the first time. We remember the ones who returned better.

It Takes What It Takes

When Nick Saban was asked what it takes to win, he said:

“It takes what it takes.”

That mindset applies here.

This is not about suffering. It is not about glorifying exhaustion. It is about readiness and reliability in a high-stakes environment.

Patients do not care how tired you are. The operating room does not lower its expectations because the week was difficult. Clinical training is structured to build consistency under pressure.

Retake the course and earn the A. Increase acuity. Take graduate sciences. Deepen your professional knowledge. Prepare for pressure. Reapply strategically.

If you did not receive an interview or an acceptance, that outcome is not a verdict on your potential. It is feedback. Feedback provides information, and information creates leverage.

What you do next determines whether this was rejection or redirection.

The comeback is always greater than the setback.

But only if you build it.

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If you did not receive an interview or an acceptance this cycle, read this before you decide what it meant. Every year we receive some version of the same message or read it on social media:

“I met the minimums. Why didn’t I get an interview?”

“I interviewed. I thought it went well. Why wasn’t I accepted?”

These are fair questions. This process is expensive, emotionally taxing, and deeply personal.

So let’s talk about how it actually works.

TL;DR

If you want an interview, you need more than minimums. If you want to be accepted, you must demonstrate readiness at a higher level. Competitive applicants show strong science performance, meaningful critical care depth, leadership, professional understanding of nurse anesthesiology, and an interview presence that holds under pressure. If you were not selected, treat it as data, close the gaps, and reapply with measurable upgrades.

Start With the Math

At our program, we routinely see 800 qualified applicants.

We interview about 100.

We accept 30.

That translates to:

• Roughly 12 percent of qualified applicants receiving an interview

• Roughly 4 percent of qualified applicants receiving an acceptance

For context:

• U.S. MD programs overall accept approximately 5 to 6 percent of applicants.

• U.S. DO programs are typically around 10 to 12 percent.

• U.S. dental schools vary, but national data often show 50 to 60 percent of applicants receive at least one offer, though individual schools remain highly competitive.

Those national figures vary by year and data source, but they help frame the level of competition applicants underestimate.

Meeting the minimum requirements makes you eligible, but it does not make you competitive. In a pool this compressed, the margin between the least and most qualified candidates is often narrower than applicants assume.

What We Actually Evaluate

There are five major domains we consider.

1. Science GPA

We have consistently found a significant correlation between science GPA and performance in:

• Didactic nurse anesthesiology coursework

• The Self-Evaluation Exam

• The National Certification Examination

Strong science performance predicts downstream success. When we analyze internal performance data, that relationship holds.

If you earned a C in chemistry, physiology, or another prerequisite, we expect remediation. That means retaking the course and earning an A.

Some applicants think expecting an A is harsh. From an admissions standpoint, it is the clearest signal of readiness.

Earning an A in an undergraduate science course will be far easier than earning A-level work in a doctoral nurse anesthesiology program. In all CRNA programs, the minimum passing grade ranges between 80 and 85 percent. Anything below that is a failure.

If you struggled in undergraduate sciences, from our perspective the difficulty curve in a nurse anesthesiology program will be significantly steeper.

Many programs replace old grades with new ones when calculating GPA. Retaking the course and earning an A demonstrate growth and materially strengthen both your academic profile and your current knowledge base.

Admissions decisions are made on documented performance, not projected potential.

2. Experience

One year of critical care experience may meet the minimum requirement.

It is rarely competitive.

Some applicants with one year believe they are ready. A few may be. Those individuals are rare outliers.

All of us who have worked in critical care understand that the nurse with one year of experience is rarely the person other nurses or providers turn to first when a patient decompensates. They are not usually the go-to for the sickest assignment.

This is because confidence without repetition is optimism. Competence requires exposure.

That may be uncomfortable to hear. It remains generally true.

Admissions committees do not build classes around statistical outliers. We evaluate based on averages.

I have voted no on applicants I personally liked because the data did not support readiness.

I have also voted yes on return applicants who proved they implemented feedback.

On average, applicants with more critical care experience, all other factors being equal, perform better during the clinical residency phase. Research across professions consistently shows that domain-specific experience improves pattern recognition, decision-making accuracy, and situational awareness over time.

We do observe diminishing returns. After roughly five to seven years of critical care experience, additional time does not appear to confer significant incremental advantage. The national average experience at admission is approximately three years.

More experience does not guarantee success.

But statistically, it improves the probability of clinical readiness.

3. Leadership

Leadership reflects maturity and initiative.

Charge roles. Precepting. Committee work. Quality improvement initiatives. Research. Additional certifications. Professional involvement.

We are selecting future colleagues who will represent, and advance, the program and the profession.

Passive resumes are easy to recognize. Strong applicants show initiative that someone else can verify. Titles matter less than impact. We look for evidence that you have influenced outcomes, not just occupied roles.

4. Knowledge of the Profession

This is where some otherwise strong applicants falter.

Most applicants know what CRNAs are paid. Salary may have initially drawn them to the profession.

That is not enough. Compensation may attract interest. It does not demonstrate commitment.

We expect applicants to understand:

• The history of nurse anesthesiology

• Practice models, including independent and collaborative environments

• Legislative and regulatory landscapes

• Scope and practice issues

• Workforce and access-to-care challenges

• What CRNAs actually do on a daily basis

If you tell an admissions committee that CRNAs only work under the supervision of a physician anesthesiologist, that signals a lack of professional understanding.

If your only talking point is compensation, that signals shallow preparation.

….and yes, we have seen both.

Your GPA and three years of critical care experience will not carry you if you cannot articulate what this profession is, how it functions, and where it is headed.

We expect thoughtful, informed candidates who have shadowed, researched, and engaged beyond surface-level metrics. This profession is defined by its responsibilities, standards, and advocacy efforts, not simply by compensation or what is visible during a shadow day.

5. Interview Performance

We have declined applicants with exceptional GPAs who performed poorly in the interview.

We have accepted applicants with less than perfect GPAs who demonstrated composure, insight, and critical thinking.

The interview is a stress test. So is a nurse anesthesiology program. So is the operating room.

We pay attention to:

• How you respond to rapid questioning

• Whether you think critically rather than recite memorized answers

• Emotional regulation

• Professionalism

Many applicants can recite information they have read online or from AI. We are not evaluating your ability to repeat search results. We are evaluating how you synthesize information, reason through uncertainty, and adapt under pressure.

Admissions decisions are democratic. Faculty vote. Every domain is discussed.

Common Pitfalls

Certain patterns recur.

Pass/fail post ADN bachelor’s programs without GPA often default to a 3.0 in evaluation systems. That is not competitive.

Retaking courses in flexible or extended formats that spread a 16-week semester across many months does not reassure committees. Anyone can earn an A with unlimited time. Programs require mastery on strict timelines, with multiple demanding courses running simultaneously.

Assuming minimums equal entitlement is a frequent mistake. Eligibility is the lowest bar. Selection is a different conversation.

Overconfidence in prior academic success can also be dangerous. Undergraduate As do not automatically translate to doctoral nurse anesthesiology As. The first failing exam can be a profound wake-up call.

Questioning whether certain standards can be bypassed is another recurring issue. Applicants occasionally ask if a weak science grade can be overlooked because of strong experience, or whether limited leadership can be offset by a high GPA. Admission is not about selectively satisfying criteria. It requires consistency across domains.

Belief alone does not carry nurse anesthesia residents through.

Study structure, protected time, and disciplined work habits do.

Belief Is Personal. Proof Is Professional.

We hear this often:

“I know I can do this.”

Many applicants believe that sincerely.

Belief must be supported by evidence the committee can verify.

We have a limited snapshot of you. We do not have years to evaluate potential. We evaluate documented evidence.

It is not enough that you believe in yourself.

You must demonstrate why we should.

Confidence ≠ Evidence.

Programs Are Accountable Too

Programs are evaluated on attrition rates, first-time board pass rates, and accreditation standards.

When a nurse anesthesia resident struggles, it affects the individual and the program.
Selection decisions must be grounded in probability of success.

Part 1 Conclusion: Selection Is Predictive

Admissions decisions are not personal, they are predictive.

Admission committees are asking a single question:

Based on the documented evidence in front of us, what is the probability this applicant will succeed in a program that does not slow down?

That is the lens.

If you were not selected, it does not automatically mean you are incapable.

It means the probability signal was not strong enough this cycle.

Next week in Part 2, I will address what many applicants misunderstand after they are accepted:

What nurse anesthesiology training actually demands once you are inside the program, and why misunderstanding that reality is one of the most common reasons strong applicants struggle.

Selection is only half the story.

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This is one of the hardest conversations in nurse anesthesiology, and one of the least talked about. This post discusses common patterns in nurse anesthesia education and is not about any individual, cohort, or program.

Every year, somewhere in the country, a nurse anesthesia resident (NAR) is dismissed or withdraws from a program. Sometimes it happens early in didactic. Sometimes after a failed progress or sim exam and remediation. Sometimes deep into clinical, when expectations finally collide with reality.

And when it happens, the same questions surface immediately:

Is this the end?

Can I ever get into another program?

Was all of this for nothing?

The honest answer is uncomfortable…. but it isn’t hopeless.

First: Let’s Strip Away the Myths

Dismissal from a nurse anesthesiology program is not a moral failure. It is not proof that someone is lazy, unethical, or incapable of being a safe clinician.

It is, however, a signal that something didn’t align:

• Learning style vs. assessment model

• Knowledge acquisition vs. high-stakes testing

• Stress tolerance vs. program intensity

• Or sometimes, life events colliding with an unforgiving academic structure

Programs are designed to be gatekeepers, not rehabilitative environments. Once a resident demonstrates they cannot meet progression standards, especially on standardized benchmarks, the program has an obligation to protect patients, accreditation, and the profession.

That obligation doesn’t come with malice. But it does come with finality.

What Often Gets Missed: Programs Do Not Want to Dismiss Residents

One of the most persistent misunderstandings is the idea that programs are quick, or see it as a badge of honor, to dismiss nurse anesthesia residents. That simply isn’t true.

From the moment a resident is admitted, the program has already made a judgment call: we believe in this person. Admission reflects a determination that the applicant is capable of succeeding, is a good fit for the program’s structure and expectations, and can ultimately graduate and enter practice safely. Programs do not admit residents hoping they will fail. They admit them because they want them to succeed.

Dismissal is not a first response. It is almost always the end of a long remediation pathway.

Programs invest extraordinary time and resources into remediation efforts, academic support, testing accommodations when appropriate, structured study plans, skills reinforcement, and repeated opportunities to demonstrate competency. Those efforts are not altruistic; they are tied to accountability.

Nurse anesthesiology programs are formally evaluated on attrition and certification examination performance, including first-time pass rates, by the COA. High attrition and poor certification exam outcomes place programs under scrutiny. COA reviews National Certification Examination pass rates on a regular schedule and can place programs on monitoring if pass rate requirements are not met.

In other words, dismissing a resident is not neutral for a program. It carries consequences. That reality further reinforces why dismissal occurs only when progression standards cannot be met despite sustained remediation.

When a resident ultimately does not progress, it is not because the program stopped caring. It is because the program exhausted its obligation to support and its obligation to protect patients, graduates, and the profession.

A Necessary Distinction: Withdrawal Is Not the Same as Dismissal

It’s also important to acknowledge something this article is not about.

Not every resident who leaves a nurse anesthesiology program does so because of academic failure, lack of capability, or inability to function clinically. Some residents withdraw for reasons entirely unrelated to their aptitude or performance such as significant personal, family, medical, financial, or life circumstances that make continued training impossible at that time.

Those cases are real, they matter, and they deserve compassion. But they are not the focus here.

What complicates matters is that many residents experiencing personal or external stressors never disclose them early. Others delay speaking up while problems quietly compound; missed clinical expectations, strained professional relationships, deteriorating evaluations, or failing didactic performance. In some cases, internal factors such as major personality conflicts with faculty or peers further disrupt an already fragile situation.

By the time these issues surface formally, they are often indistinguishable on paper from performance-based deficiencies. At that point, recovery becomes significantly more difficult, not because support was unavailable, but because the window to intervene meaningfully has narrowed.

When residents are struggling, whether the cause is personal, interpersonal, or academic, coming forward early matters. Early disclosure allows program leadership to understand the context, assess what is modifiable, and determine whether accommodations, support, or temporary adjustments are possible. Silence, delay, or attempting to push through alone almost always worsens the outcome.

Programs cannot help with what they do not know, and they cannot pause objective progression standards once deficiencies are formally established.

Where People Often Go Wrong Immediately After Dismissal

The instinctive response is panic, and panic leads to bad decisions.

Common missteps I see:

• Immediately applying elsewhere without reflection

• Minimizing or reframing the dismissal

• Blaming faculty, testing agencies, or “toxic programs”

• Trying to litigate or narrative-engineer their way out of documented outcomes

Here’s the reality most applicants don’t want to hear:

Nurse anesthesiology is a small world.

Clinical sites, CRNAs, and NARs may talk, even when program administrators and faculty cannot.

Transcripts and evaluations tell a story, whether you want them to or not.

Can Someone Get Into Another Program?

Yes… but rarely, and only under specific conditions.

Successful re-entry cases typically share all of the following:

1. Time away (often years, not months)

2. Clear academic remediation (graduate-level coursework with excellence)

3. Honest ownership of why dismissal occurred

4. A changed variable (testing approach, support structure, environment)

5. Strong, credible advocacy from anesthesia professionals willing to vouch, not pity

What does not work:

• “I just had a bad semester”

• “The program wasn’t supportive”

• “I know the material, I’m just bad at exams”

• “This other program will be different”

Programs are not betting tuition dollars on hope. They are betting on demonstrated change.

Objective evidence usually looks like actions and outcomes, not a promise. Examples may include:

• Graduate-level science coursework completed with strong grades

• A clear testing plan with documented improvement over time

• Strong recent clinical performance and credible references in critical care

• A stable, sustainable life plan that supports the intensity of training

• Professional support for any prior barriers, with a clear plan for durability

• A transparent, consistent explanation that matches documentation from the prior program

Disclosure, Releases, and the Reality of Reapplying

When applying to a nurse anesthesiology program after withdrawing from or failing to complete a prior program, disclosure is not optional. Applicants are required to report prior enrollment in a nurse anesthesiology program and whether that program was completed.

In most cases, applicants should expect to sign a FERPA release authorizing communication between the program to which they are applying and the prior program. New program leadership may speak directly with the previous program director, request written documentation from the prior program, and will almost certainly require a written explanation from the applicant addressing three core questions: why the prior program was not completed, why they believe they will succeed now, and what concrete steps have been taken in the interim to ensure a different outcome.

This process is not punitive; it is due diligence.

Nurse anesthesiology programs are highly competitive. Many programs routinely see 20 to 30 qualified applicants per available seat, sometimes more. In that context, admitting an applicant who did not complete a prior program represents a measurable risk. For a program to take that risk, there must be compelling, objective evidence that the applicant will not only succeed academically and clinically, but also represent the program well through graduation and certification. While every applicant in this position genuinely believes things will be different this time, belief alone is not evidence. Programs must be able to see, through actions and outcomes, why they should share that confidence.

Programs are also formally evaluated on attrition and certification examination outcomes, including first-time pass rates, by the Council on Accreditation of Nurse Anesthesia Educational Programs (COA). Those metrics matter. They create strong incentives for programs to be cautious and to avoid avoidable risk unless an applicant can demonstrate clear, credible reasons for confidence in future success.

Reapplication is possible, but it is never casual, and it is never based on assurances alone.

The Hardest Truth: Sometimes the Answer Is No

This is the part no one wants to publish.

For some individuals, the answer is not “try again.” It’s redirection. And that doesn’t mean failure.

I’ve watched former residents build meaningful, respected careers in:

• Advanced practice nursing roles

• Critical care leadership

• Education and simulation

• Industry, informatics, policy, and administration

What they lost was a specific role, not their value or professional worth.

Holding onto an identity that no longer fits can do more damage than letting it go.

What Programs Actually Look For If Someone Reapplies

If you’re wondering what sits behind closed doors during admissions discussions, it’s this:

• Risk assessment, not empathy

• Pattern recognition, not promises

• Evidence of change, not explanation

A prior dismissal raises one overriding question:

What is different now that wasn’t different then?

If that answer isn’t concrete, measurable, and externally validated, the application stops there.

For Current Residents Reading This

If you’re struggling right now:

• Ask for clarity early

• Ask for data, not reassurance

• Ask what objective benchmark determines progression

And if you’re on the edge, don’t let silence or pride be the reason the decision gets made for you.

Withdrawal with insight is very different from dismissal without it.

Final Thought

Dismissal from a nurse anesthesiology program is devastating. I won’t minimize that.

But the real danger isn’t the dismissal itself, it’s letting it define you without reflection, growth, or redirection.

Sometimes the dream survives. Sometimes it evolves.

And sometimes the bravest move is choosing a different future altogether.

What matters most is not how the story paused, but whether you learned enough to write the next chapter honestly.

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Every few months, the same question resurfaces, usually from someone outside anesthesia, or someone considering nurse anesthesiology:

**Why does CRNA education still require critical care experience?**

**Is one year really necessary?**

**Does critical care time actually translate to anesthesia practice?**

Yes.

If you’ve worked real critical care, you already know why. If you haven’t, it can look like an arbitrary checkbox.

Because this requirement only makes sense once you understand what anesthesia actually is.

Anesthesia is not a collection of technical tasks. It is real-time physiologic management of unstable patients during intentional physiologic stress, often with no margin for delay or correction.

The Minimum Is a Floor, Competency Is the Target

The published minimum for all CRNA programs is one year of critical care but but the American Association of Nurse Anesthesiology notes that CRNAs enter formal anesthesia education with an average of about three years of critical care experience.

That number isn’t magic, and it isn’t a claim that “more time automatically equals better.” Time is a crude proxy. Competence is the goal.

The real issue is this: anesthesia training assumes you already speak the language of unstable physiology. Critical care is the most reliable place to build that baseline fluency before the learning curve steepens.

Also, “one year in an critical care unit” isn’t a standardized experience for everyone. Unit acuity and assignment patterns vary. So does whether you take the initiative to get personally involved in driving the plan versus simply carrying it out without understanding why.

So when programs favor applicants with more than the minimum, they’re usually not rewarding a calendar, they’re reducing the risk of admitting someone whose clinical exposure hasn’t yet forced the pattern recognition, prioritization, and follow-through anesthesia demands.

Anesthesia Is Critical Care, Just Compressed

The operating room doesn’t replace the ICU or ED. It shortens the distance between cause and effect.

In critical care, deterioration may unfold over hours or days. In anesthesia, it can unfold in seconds. The case doesn’t pause while you think, physiology keeps moving.

Induction is controlled cardiovascular collapse. When it’s done well, it looks routine. When it’s done poorly, you don’t get a slow decline, you get a sudden one.

Positive pressure ventilation immediately alters preload and afterload.

Anesthetic agents suppress compensatory physiology by design.

Blood loss, ischemia, reperfusion, and inflammatory responses are expected, not rare.

CRNAs don’t simply react to instability.

We anticipate it.

That anticipation comes from prior exposure to instability, repeatedly, until patterns become reflex.

ICU Experience Teaches Trajectory, Not Tasks

The value of critical care experience is not that someone once titrated a vasopressor.

It’s that they:

• Managed the same patient over time

• Watched physiology improve, stall, or unravel

• Learned when numbers matter… and when they mislead

• Saw how small decisions compound into big outcomes

• Balanced competing priorities (oxygenation vs hemodynamics, sedation vs ventilation, fluids vs pulmonary edema)

Critical care clinicians learn trajectory thinking.

Where the patient is headed matters more than where they are right now.

That same thinking allows a CRNA to recognize:

• The “acceptable” blood pressure that isn’t acceptable for this patient

• The subtle ventilatory change that precedes hypoxia

• The preload-dependent patient who will crash after induction

That is a highly honed intuition developed through the lens of experience. Without that experience, anesthesia decisions become reactive instead of anticipatory, and reactivity in anesthesia is where complications live.

The Medication Overlap Is Not Accidental

Another common misconception: critical care medications don’t translate to anesthesia. They do.

• Vasopressors

• Inotropes

• Sedatives

• Analgesics

• Neuromuscular blockers

• Antiarrhythmics

The difference isn’t which drugs are used. It’s how fast the consequences arrive and how little time there is to correct a bad decision.

Critical care experience teaches pharmacology in real patients with comorbidities, competing priorities, and fragile physiology. That context matters when decisions are measured in seconds.

Why Programs Look Beyond the Minimum

Here’s the trap: turning this into a “more time is always better” argument.

Calendar time is an imperfect stand-in for readiness. Competence is the goal, and competence shows up as judgment under pressure.

Programs look for applicants who can already think in physiology because nurse anesthesiology education moves fast, and the OR does not pause while you catch up.

More-than-minimum experience often correlates with readiness because it increases the odds you have:

• Managed complex patients long enough to see cause → effect → consequence

• Owned ventilator and hemodynamic decisions, not just followed orders

• Learned to prioritize when multiple problems evolve at the same time

Plenty of excellent applicants reach that level in the minimum timeframe. Others need longer depending on acuity and role. The point is not the number, it’s the preparation you bring into training.

One more nuance: “high-acuity” isn’t always synonymous with “high-autonomy” or demonstrated critical thinking capacity. Some large tertiary, academic medical centers have robust support infrastructure and tightly segmented workflows. That can deliver excellent care, but it doesn’t always translate into the independent prioritization that nurse anesthesiology demands. In many rural and community hospital ICUs, nurses are accustomed to doing the most with limited resources and problem-solving without dedicated IV and Foley teams, or respiratory therapy immediately available to troubleshoot vents and draw blood gases. Environment matters, but autonomy and independent thinking can matter more.

Preparation, Not Gatekeeping

The critical care requirement isn’t about keeping people out.

It’s about ensuring applicants arrive prepared to learn anesthesia, not overwhelmed by physiology they’ve never managed before.

Critical care experience ensures baseline fluency in:

• Ventilator physiology

• Hemodynamic trade-offs

• Multi-organ interactions

• Managing instability when you ARE the rescue

That foundation allows anesthesia education to focus on advanced decision-making not constant remediation.

Final Thought

The one-year critical care requirement is the minimum because a line has to be drawn somewhere. The reason critical care remains a prerequisite is simple:

Anesthesia demands judgment before it demands technique.

Judgment is built through repeated exposure to instability, uncertainty, and consequence, and through owning the outcome.

That is what high-acuity critical care provides *before* anesthesia training begins.

CRNA education then converts that foundation into anesthesia-specific judgment: rapid assessment, precise intervention, and constant reevaluation.

In anesthesia education, we routinely prepare learners for events they may only see once or twice in an entire career. Failed airways. Emergency cricothyrotomy. High thoracic epidurals. Anatomical variation under stress.

Yet much of how we teach anatomy and procedures remains abstract, two-dimensional, or dependent on expensive simulators that are often locked away, shared across departments, or used infrequently. Three-dimensional printing changes that equation.

3D Printing in Anesthesia Education: A Practical Shift

Three-dimensional (3D) printing has moved from novelty to practical utility in medical education. Originally developed for industrial prototyping, additive manufacturing is now widely used to create anatomical models for teaching, procedural rehearsal, and simulation based mastery learning. Its educational value lies in the ability to convert imaging and digital models into physical objects that can be handled, inspected, and practiced on.

For anesthesia education, where spatial understanding, hand mechanics, and anatomical variability directly affect patient safety, this matters. Screens and slides are helpful, but they cannot replace physically interacting with anatomy.

Why 3D Printing Matters in Anesthesia Education

Traditional tools such as textbooks, lectures, and even many commercial simulators struggle to replicate real anatomy or support repeated deliberate practice.

Patient specific anatomical fidelity

Imaging data from CT or MRI can be converted into physical models through segmentation and basic design workflows. This allows learners to study real anatomical variation rather than idealized textbook anatomy, which is particularly relevant for airways, vertebral anatomy, and vascular structures.

Spatial and tactile learning

Holding anatomy in your hands changes how it is understood. Physical models reinforce relationships between depth, angle, and orientation in ways two dimensional images cannot. This matters for procedures where millimeters and degrees make the difference between success and failure.

Repetition without risk

Low-cost printing allows procedures to be practiced repeatedly without exposing patients to harm. This is especially valuable for rare but high consequence skills that degrade quickly without rehearsal.

Equity and access

When models can be printed locally, education is no longer dependent on expensive proprietary simulators. This has major implications for smaller programs, rural training sites, and resource constrained settings.

Where 3D Printing Is Already Being Used in Anesthesia Training

Airway Management and Bronchoscopy

3D printed airway and tracheobronchial models are increasingly used to teach difficult airway anatomy, bronchoscopy navigation, and procedural planning. Models can be customized to reflect pediatric airways, distorted anatomy, or pathology that learners may rarely encounter clinically.

Several European anesthesia groups have reported using printed airway models for preoperative planning in anticipated difficult airway cases, allowing teams to rehearse strategy before patient contact.

3D Printed Laryngoscopes in Simulation Training

3D printing can also be used to recreate everyday airway tools, including laryngoscopes, for simulation and skills training. Printed laryngoscope handles and blades allow learners to repeatedly practice grip, positioning, and mechanics without competing for limited equipment or risking damage to clinical devices.

In simulation labs, these models are particularly useful for early airway training, remediation, and repetitive practice. Learners can focus on hand position, blade insertion, lifting mechanics, and visualization technique without the pressure of patient care or the constraints of shared equipment.

Because these models are inexpensive and easily reproduced, they can be distributed widely across simulation spaces, resident practice rooms, or even used for self-directed learning. While they are not intended to replace clinical laryngoscopes, they lower barriers to repetition, which is where real skill acquisition occurs.

When paired with airway mannequins or task trainers, 3D printed laryngoscopes allow programs to scale airway education in a way that is difficult to achieve with traditional equipment alone. The setup shown can be produced for approximately $30–$50 in materials.

Neuraxial and Epidural Simulation

Low-cost, do-it-yourself 3D printed thoracic spine models have been described as an alternative to commercial epidural simulators. Learners reported improved understanding of vertebral anatomy, needle trajectory, and loss of resistance mechanics. Importantly, these models cost a fraction of commercial systems while remaining anatomically instructive.

This approach aligns well with how anesthesia is actually learned through repetition, feedback, and progressive independence.

Emergency Cricothyrotomy

Emergency surgical airways are among the highest stress, lowest frequency procedures we expect anesthesia providers to perform. Procedural memory degrades rapidly under stress, and any procedure not practiced is unlikely to be performed well when it matters.

3D printed cricothyrotomy trainers allow repeated hands on practice of incision, membrane identification, and tube placement. If a model saves one life in an entire career, the return on investment is self evident.

Regional Anesthesia and Brachial Plexus Models

Printed brachial plexus models help learners visualize nerve relationships that are otherwise difficult to conceptualize, even with ultrasound. When combined with ultrasound teaching, these models reinforce probe orientation, needle path planning, and three-dimensional anatomy.

Everyday Clinical Tools

Beyond simulation, programs are printing practical accessories such as label dispensers, ultrasound probe holders, and organizational tools. These small prints reinforce a culture of clinician driven problem solving and innovation.

Implementation: How Programs Can Actually Do This

This is where 3D printing stops being theoretical and becomes realistic.

Why Bambu Lab Printers Are a Practical Entry Point

For anesthesia programs, Bambu Lab printers represent one of the lowest friction entry points into 3D printing.

• Plug and play setup with minimal calibration

• Integrated software ecosystem that includes slicing and printer management

• High print reliability with minimal user intervention

• Multi material and multi color capability without complex workflows

• Cost that is realistic for departmental or simulation budgets

A novice user can go from unboxing to printing a functional educational model in a single afternoon. That matters in academic environments where faculty time and technical support are limited.

These printers remove barriers. Educators can focus on teaching rather than troubleshooting hardware.

Software Workflow

Most educational prints can be managed entirely within the Bambu software ecosystem or with widely available tools such as Fusion for basic design modification. Even if you do not want to learn how to make your own models, many high quality models are already available from open repositories and often require no adjustments before printing.

Evidence and Educational Outcomes

The broader medical education literature consistently shows that 3D printed models improve comprehension of complex anatomy, learner engagement, and confidence when paired with structured instruction. While anesthesia specific outcome data are still emerging, early evidence and practical experience support their value for procedural readiness and skill acquisition.

The key is not the printer. It is how the model is integrated into deliberate practice, feedback, and assessment.

Limitations and Reality Checks

3D printing is not a replacement for all simulation.

• Low cost printing materials are obviously not the same as a patient

• Minimal time is required for model preparation and printing

• Models must be tied to learning objectives, not used as novelty items

Used poorly, a printed model is just plastic. Used well, it becomes a force multiplier for education.

Clinical Pearls

• High risk, low frequency procedures yield the greatest educational return

• Physical models work best when paired with structured feedback and assessment

• Accessibility matters more than perfection

• If learners can practice more often, outcomes improve

For anesthesia programs, the question is no longer whether this is possible, but whether we are willing to pilot it.

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One of the most misunderstood parts of nurse anesthesiology education is the 1:2 clinical teaching model, where one CRNA supervises two Nurse Anesthesia Residents in concurrent rooms.

I hear concerns about it regularly. Some people worry it is unsafe. Others think it is about staffing. Some assume it exists to squeeze more productivity out of residents.

The 1:2 teaching model has been part of federal teaching rules for more than a decade because it reflects how supervised autonomy is intentionally taught in anesthesia education when applied as CMS and the COA intended. When implemented as designed, the 1:2 model is not a shortcut; it is a structured, accountable method of preparing nurse anesthesia residents for independent clinical practice.

What the 1:2 model actually looks like in real life

Under Medicare’s anesthesia teaching rules, a non-medically directed CRNA may supervise two Nurse Anesthesia Residents at the same time, one in each of two rooms, and bill the full allowable amount for both cases. That has been true since 2010.

CMS did not create this model arbitrarily. It was intentionally aligned with how physician anesthesia residents are trained and billed under Medicare. The expectation is supervision, availability, and accountability, not constant physical presence in two rooms at once.

In real terms, this means the preceptor is fully responsible for both anesthetics. They review the plan, are present for critical portions, and remain immediately available throughout the case. Their time is devoted to those two rooms and nothing else.

That structure is familiar to anyone who has worked in academic anesthesia environments. It is not experimental and it is not new.

Why this matters for Nurse Anesthesia Residents

Neither physician anesthesia residents nor nurse anesthesia residents become independent clinicians by being observed every second of every case. They become independent by learning how to think, anticipate, adjust, and recover under supervision.

The 1:2 model creates room for that growth, especially for senior residents who are approaching graduation. When a preceptor is in the adjacent room rather than standing at the head of the bed, something important happens. The resident owns the anesthetic in a way that is difficult to replicate otherwise.

• They still present their plan.

• They still get approval.

• They still know help is immediately available.

What changes is the internal process. Decisions feel real. Timing matters. Small judgment calls belong to the resident. Confidence builds because it has to.

I have seen this repeatedly. Residents who struggle under constant micromanagement often thrive when given structured space. They stop performing for approval and start practicing anesthesia.

That transition is essential if we expect graduates to function safely and confidently the day they are credentialed.

A small example that illustrates a bigger problem

Anyone who has trained in anesthesia, whether as a physician anesthesia resident or a nurse anesthesia resident, has experienced some version of this.

You draw up a medication. You label the syringe. The label is clear, legible, and compliant. Then the preceptor stops you, not because the drug is wrong or the dose is unsafe, but because the label is wrapped around the barrel instead of placed lengthwise along the syringe. Or because it is too close to the hub. Or because it should never cover the volume markings. Or because it always should.

The explanation changes depending on who is standing behind you. One person insists their way is safer. Another says their way is more visible. Another says it prevents errors, even though the syringe is already correctly labeled and identifiable. None of these preferences are standardized. None of them are evidence-based. All of them are enforced.

What makes it frustrating for learners is not the correction itself. It is the message behind it. The message is that even when something is done correctly, it still must be done exactly someone else’s way. Not for safety. Not for compliance. Simply because that is how they prefer it.

When this happens repeatedly, learners stop thinking about the anesthetic and start thinking about approval. They focus on avoiding minor criticism instead of developing judgment. Over time, it conditions them to perform rather than practice.

That kind of micromanagement feels small in the moment, but its cumulative effect is real. It narrows autonomy, erodes confidence, and delays the transition from trainee to independent clinician.

The 1:2 teaching model does not eliminate feedback or standards. It limits the impulse to control details that do not meaningfully affect patient safety. It allows learners to focus on decisions that actually matter.

Why clinical departments benefit as well

Beyond education, the 1:2 model also matters at the departmental level. From a department perspective, the 1:2 model offers flexibility without sacrificing safety or compliance.

When used correctly, it allows an additional operating room to function during times when two residents are available. It can provide some breathing room for preceptors during long days. It can help departments absorb staffing variability without closing rooms or delaying cases.

CMS allows full reimbursement for both cases when supervision requirements are met. That matters because it allows education and operations to coexist without forcing departments to choose between the two.

This is not about squeezing more work out of residents. It is about recognizing that education happens inside real clinical systems and that those systems still have to function.

The “free labor” concern deserves a clearer explanation

The COA is explicit that Nurse Anesthesia Residents may not be employed or function as anesthesia providers by title or role. Their participation in cases is educational and supervised.

At the same time, it is unrealistic to pretend that learners do not contribute to patient care. Physician anesthesia residents have always contributed while learning in a 1:2 ratio. Framing that participation as exploitation overlooks how graduate clinical education has historically functioned across healthcare professions.

• Nurse anesthesiology follows the same logic.

• Residents do not bill.

• Residents are not credentialed providers.

• Residents are not practicing independently.

The supervising CRNA remains responsible for the anesthetic and is the billable provider under CMS rules. The resident is there to learn through participation, not observation alone.

What CMS expects, in plain terms

For a CRNA to supervise two residents concurrently and bill appropriately, CMS expects a few key things.

1. The CRNA must be immediately available to both rooms.

2. They must be present for the pre-anesthesia evaluation and post-anesthesia care for each patient.

3. They must be present for critical portions of the anesthetic.

4. They must devote their professional time to those two cases.

5. They must document supervision clearly and accurately.

When those conditions are met, both cases are payable at 100 percent under the non-medically directed CRNA model.

This is not an aggressive interpretation of the rules. It is the rule.

What the COA requires

The Council on Accreditation allows a maximum supervision ratio of two nurse anesthesia residents to one preceptor. That limit exists to protect patient safety and the educational environment.

The COA also makes it clear that supervision must take into account case complexity, patient comorbidities, and the resident’s level of training. Immediate availability is required. Accountability is required.

What the standards do not require is constant physical presence in two rooms at the same time. They require responsible oversight by qualified anesthesia professionals.

That distinction matters.

A practical way to implement the model safely

1. Programs and facilities that use the 1:2 model well tend to approach it deliberately.

2. They reserve it for residents who have demonstrated readiness.

3. They are clear about what counts as a critical portion of care.

4. They train preceptors on how to supervise without micromanaging.

5. They document consistently and carefully.

6. They align internal policy with CMS and COA language.

When those pieces are in place, the model functions smoothly and predictably.

The bottom line

Graduation is not the moment someone suddenly becomes ready for independent practice. That readiness has to be built ahead of time. In many practice settings, CRNAs enter environments where they are the sole anesthesia professional in the room, responsible for assessment, planning, execution, and recovery without immediate in-room backup.

The 1:2 teaching model is one of the tools that allows that transition to happen in a supervised, accountable way. It prepares residents for real practice while supporting the operational realities of clinical departments.

Used correctly, it strengthens education rather than diluting it.

If we want graduates who can think independently, manage uncertainty, and practice safely without constant oversight, we have to be willing to teach that skill before they graduate.

When applied deliberately and within established standards, the 1:2 model helps do exactly that.

References

Centers for Medicare & Medicaid Services. Medicare’s New Anesthesia Payment Teaching Rules. Final Rule, 74 Fed. Reg. 61738, November 25, 2009.

Centers for Medicare & Medicaid Services. Teaching Rules Payment Scenarios Under the Medicare Physician Fee Schedule. Effective January 1, 2010.

Council on Accreditation of Nurse Anesthesia Educational Programs. Standards for Accreditation of Nurse Anesthesia Programs: Practice Doctorate. Approved May 21, 2025; effective January 1, 2026.

American Association of Nurse Anesthesiology (AANA). Medicare’s New Anesthesia Payment Teaching Rules. Office of Federal Government Affairs, March 2011. Summary and interpretation of the CMS Final Rule implementing MIPPA Section 139 (74 Fed. Reg. 61738, November 25, 2009).

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I’m interested in how widely this model is understood and used across different practice settings.

Certified Registered Nurse Anesthetists provide anesthesia care for millions of patients each year in hospitals, ambulatory surgery centers, military facilities, and rural communities. Most patients never meet their anesthesia provider until moments before surgery, yet they entrust them with the most vulnerable aspects of care: unconsciousness, pain control, physiologic stability, and safe recovery.

What is far less visible is how CRNAs are educated to assume that responsibility. Outside of anesthesia, the structure, intensity, and intentional design of CRNA education are often misunderstood. This article is not about comparison or titles. It is about explaining, clearly and accurately, what it actually takes to prepare clinicians for safe anesthesia practice.

CRNA education is not a single pathway or skill set. It is deliberately built on four integrated pillars:

1. Didactic education

2. Clinical education

3. Scholarly work

4. Professional development

Education Built for Responsibility

CRNA education is not designed to create observers, assistants, or technicians. It is designed to prepare clinicians who will be accountable for moment-to-moment anesthetic decisions across diverse practice settings. That responsibility shapes every aspect of training.

Rather than separating theory from practice, CRNA education intentionally integrates scientific knowledge, clinical application, and professional judgment from the beginning. The goal is not memorization, but understanding.

Didactic Education: The Science Behind Safe Anesthesia Care

CRNA students complete doctoral-level coursework that provides a deep, applied understanding of human physiology and anesthetic management. This includes advanced study of physiology and pathophysiology, enabling students to understand how disease processes affect every organ system during anesthesia and surgery.

Equally critical is advanced pharmacology, with focused education on anesthetic agents, adjunct medications, and vasoactive drugs that directly influence consciousness, analgesia, blood pressure, and cardiac function. Students also study chemistry and physics as they apply to anesthesia, forming the foundation for the safe use of anesthetic gases, ventilation systems, and advanced monitoring technologies.

Additional coursework includes:

• Advanced health assessment and diagnostics

• Anesthesia principles, equipment, and technology

• Research methods, statistics, and evidence-based practice

This academic foundation prepares graduates not only to deliver care, but to critically evaluate emerging evidence and apply it appropriately in real clinical environments.

Why Scientific Depth Matters at the Bedside

Patients receiving anesthesia today are often older, medically complex, and undergoing procedures in high-pressure environments. This robust scientific foundation allows CRNAs to anticipate physiologic changes, prevent complications, and make rapid, evidence-based decisions when conditions change.

Strength of the training: CRNA education emphasizes understanding mechanisms, physiology, and cause-and-effect relationships—producing clinicians who can recognize instability early and intervene appropriately.

Clinical Education: Applying Knowledge Where It Matters Most

Clinical education places CRNA students directly into real patient care environments under expert supervision. Students progressively assume responsibility for anesthesia management across a broad spectrum of surgical and procedural settings.

Clinical training includes experience with:

• Diverse patient populations and acuity levels

• Multiple surgical specialties and anesthesia techniques

• Crisis recognition and management

• Increasing autonomy based on demonstrated competence

This progression ensures that graduates are not only technically capable, but clinically mature.

Why Real-World Training Matters

Healthcare systems increasingly rely on clinicians who can deliver consistent, high-quality care across varied settings. CRNAs are trained in high-volume, high-stakes environments, equipping them to respond effectively to both routine cases and unexpected emergencies.

This adaptability supports access to anesthesia services in underserved areas and strengthens system resilience amid ongoing workforce shortages.

Strength of the training: Clinical education emphasizes competence, judgment, and responsibility, preparing graduates for real-world practice, not perpetual supervision.

Scholarly Work: Strengthening Care Through Evidence and Innovation

Doctoral CRNA education requires completion of a scholarly project focused on improving patient outcomes, safety, education, or healthcare systems. These projects are grounded in scientific literature and designed for clinical relevance.

Why Evidence Translation Matters

Modern healthcare depends on clinicians who can evaluate evidence, identify gaps in care, and implement improvements. CRNAs are trained to translate research into practice, supporting safer, more efficient, and more effective anesthesia care.

Strength of the training: CRNAs graduate with the skills to bridge the gap between research and bedside care.

Professional Development: Preparing Leaders in Healthcare Delivery

Professional development is woven throughout CRNA education and includes ethics, leadership, healthcare policy, economics, and interprofessional collaboration.

Why Leadership and Ethics Matter

Safe anesthesia care does not occur in isolation. It requires effective teamwork, ethical decision-making, and system-level awareness. CRNAs are prepared to function as clinical leaders, advocate for patients, and contribute to sustainable care delivery models.

Strength of the training: Professional development reinforces responsibility, communication, and patient-centered care throughout the educational process.

What CRNA Education Is Not

CRNA education is not shortened, casual, or incidental. It is not built around minimal exposure or narrow case experience. It does not rely on protocol adherence alone, nor does it assume ideal conditions or unlimited resources.

Instead, it prepares clinicians for variability. Patients who do not follow algorithms. Situations where physiology changes quickly. Environments where judgment matters more than checklists. This is not unique to anesthesia, but it is essential to it.

Addressing Common Misconceptions About CRNA Education and Rigor

A persistent misconception is that CRNA education is somehow abbreviated, derivative, or less rigorous than other anesthesia training pathways. In reality, CRNA education is distinct by design, not deficient. It is structured around early immersion in critical care nursing, followed by doctoral-level scientific coursework and thousands of hours of supervised clinical anesthesia experience focused exclusively on perioperative and procedural care. Unlike models that separate decision-making from bedside execution, CRNA training integrates physiology, pharmacology, and clinical judgment from the outset, producing clinicians who are accustomed to managing complex patients independently in real-world environments. The rigor of CRNA education is reflected not only in program intensity and attrition standards, but in sustained outcomes: decades of safe anesthesia delivery across high-acuity hospitals, ambulatory centers, military settings, and rural communities. Misunderstanding this pathway often stems from unfamiliarity with its structure, not from a lack of substance or accountability.

The Big Picture: Why This Education Model Works

Anesthesia care carries significant risk and responsibility. CRNA education is intentionally rigorous because patient safety depends on it. By integrating:

• Advanced scientific coursework

• Extensive supervised clinical experience

• Scholarly inquiry and quality improvement

• Professional leadership development

CRNA programs produce clinicians who are safe, adaptable, and prepared for independent practice.

Understanding how CRNAs are educated matters, not for professional debate, but for patient care across hospitals, surgery centers, military facilities, and rural communities nationwide.

In anesthesia, you don’t get to pause the encounter to look up the rules; you execute with what you know and you’d better have a backup plan.

Most people don’t expect Advanced Dungeons & Dragons to have anything to do with anesthesia.

But long before I managed airways, titrated vasopressors, or taught nurse anesthesia residents, AD&D trained how I think, communicate, and make decisions under pressure. It shaped my approach to uncertainty, teamwork, and leadership in ways that formal education often doesn’t.

It made me a better clinician.

And it explains why some people thrive in CRNA school, and others don’t, regardless of GPA.

You Rarely Get the Whole Story

At its core, AD&D is structured problem-solving.

You are given partial information, a dynamic environment, competing priorities, and real consequences. Every decision forces you to ask:

• What do we actually know?

• What could go wrong?

• Who is best suited for this task?

• What’s the backup plan?

That is anesthesia thinking.

When blood pressure drops after induction, you’re triaging causes in real time; depth, preload, afterload; while keeping your exit ramps open.

In clinical practice, we assess physiology, anticipate second- and third-order effects, allocate resources, and plan for failure before it happens. AD&D trains you to think forward rather than react, a mindset that translates directly to safe anesthesia care.

The Patient Isn’t a “Case.” It’s a Character Sheet.

• Airway = what’s your primary plan, and what’s the rescue sequence?

• Reserve = how much “hit points” does this physiology actually have today?

• Triggers = what events change the encounter fast (induction, positioning, surgical stimulation, emergence)?

• Resources = what tools, people, and time do we have if the plan breaks?
  In both AD&D and anesthesia, you don’t win by being surprised less, you win by being surprised well.

Roles Save Teams. Ego Kills Them.

Every AD&D group has defined roles. When people ignore them, or let ego drive decisions, the group fails.

Clinical anesthesia works the same way.

Strong CRNAs know when to lead, when to support, and when to speak up. They respect the expertise of others and understand that outcomes depend on coordination, not dominance.

AD&D teaches early that no one succeeds alone, and that teams fail fastest when individuals try to do everything themselves.

Precision Is a Safety Tool

In AD&D, vague communication leads to bad outcomes. Precision matters. Assumptions are costly.

You also learn quickly that people process information differently. Some need details. Some need the big picture. Some need reassurance. Others need direct instruction.

That lesson maps cleanly to anesthesia practice, communicating with surgeons, nurses, techs, patients, and students under cognitive load. CRNA school doesn’t just test knowledge. It tests whether you can communicate clearly when it counts.

A “Bad Roll” Isn’t the End, It’s Data: Failure as Feedback.

AD&D normalizes failure.

Bad decisions don’t end the story, they change the environment. You adapt and move forward.

That mindset is essential in anesthesia. Complications are not moral failures. Near-misses are data. Growth depends on learning rather than freezing or becoming defensive.

Clinicians who struggle most often aren’t lacking intelligence. They struggle with adaptability, emotional regulation, and recovery after mistakes. AD&D quietly builds resilience by design.

Why This May Predict Who Thrives in CRNA School

Here’s a tough reality: when people struggle in CRNA programs, it’s often not because they’re incapable of learning the science. More commonly, the friction shows up in adaptability, communication, stress tolerance, and recovery after mistakes, especially when cognitive load spikes.

Successful applicants and residents tend to:

• Think in contingencies

• Understand group dynamics

• Accept feedback without defensiveness

• Stay functional under pressure

Those traits aren’t memorized. They’re learned through complex, interactive problem-solving environments. AD&D just happens to be one many of us encountered early.

Physiology Is the Dungeon Master

In AD&D, the Dungeon Master isn’t “out to get you.” The DM adjudicates the world: actions have consequences whether you like them or not.

That’s physiology in anesthesia. It doesn’t care about confidence, intentions, or credentials. It responds to what you actually do, and it will enforce the rules in real time.

The job is learning to make good moves with incomplete information, then adjusting quickly when the world responds differently than you expected.

Anesthesia Is a Live Campaign, Not a Script

Textbooks give rules. Clinical practice gives variability.

Every anesthetic is a live scenario:

• Patients don’t follow plans

• Physiology doesn’t care about intentions

• Conditions evolve in real time

The best CRNAs aren’t rigid rule-followers. They are principled improvisers, grounded in fundamentals but capable of adapting when the situation changes.

That skill is learned.

Final Thought

I didn’t become a good CRNA because I played AD&D.

But AD&D trained the mental frameworks modern anesthesia demands: critical thinking, communication, teamwork, resilience, and adaptive decision-making.

If we’re serious about preparing future CRNAs, not just selecting high GPAs, we should value experiences that shape how people think, not just what they know.

Sometimes the most formative training doesn’t happen in a classroom.

Sometimes it happens around a table, rolling dice, learning how to think together.

I’m curious what other “unexpected training grounds” shaped how you practice, sports, music, military, aviation, gaming, parenting. What taught you to think under pressure before healthcare ever did?

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Faith on the Front Line: The Quiet Leadership of Dr. Eric Kramer

Some people talk about service. Others pack their bags, step into the hardest places on Earth, and do the work. Dr. Eric Kramer is the latter. He has always been the latter. Those of us who work with him in National University’s Doctorate of Nurse Anesthesiology program see it every day. What most people do not see is how deep that conviction runs.

Dr. Kramer is driven by his faith and by a belief that leadership means stepping into hard places with purpose. Not for recognition. Not for applause. Simply to carry out a responsibility he feels called to. That is the kind of servant leadership that shapes a program, a profession, and the residents who learn under him.

A Faculty Member Who Teaches by Doing

In our DNAP program, Dr. Kramer has been the driving force behind medical mission work since the day he arrived. He has coordinated and led resident participation in global service trips to Kenya, Saipan, and other regions where access to anesthesia care is fragile or nonexistent. He challenges our nurse anesthesiology residents to see the world beyond their immediate surroundings and to understand what their training means for people who truly have no one else.

He raises the standard and then quietly exceeds it himself.

Residents know him as the faculty member who shows up for them. Our leadership knows him as someone who consistently advances our program with high quality instruction, a calm sense of purpose, and a deep commitment to excellence.

A Lifelong Pattern of Stepping Into Hard Places

Ukraine was not his first frontline. It was simply the latest.

Dr. Kramer’s presentation “From ISIS to Ebola” reveals a career built around a single through-line: whenever the world produces suffering that most clinicians would run from, he runs toward it. This is not a metaphor. It is documented reality.

Serving the Tarahumara (Raramuri) people in remote Mexico

His early mission work took him deep into the Sierra Madre, serving the Tarahumara people in one of the most underserved regions in the Western Hemisphere. There, he cared for profoundly marginalized communities experiencing malnutrition, maternal mortality, and a near-total lack of medical infrastructure. He performed anesthesia in small two-OR mission hospitals, responded to nighttime emergencies, treated pediatric seizures, and cared for infants in critical respiratory failure. These were not elective surgery days. They were episodes of crisis care with no backup and no margin for error.

He managed everything from obstetric emergencies to “zero-resource” pediatric codes, often with improvised equipment and no access to higher-level transport. At one point, cartel violence forced their team into lockdown. Still, they served.

Witnessing the brutality of cartel-related trauma

His missions exposed him to gunshot wounds, machete trauma, compound fractures, and violence that would overwhelm even seasoned trauma teams. He stabilized patients in dirt-floored rooms, pickup truck beds, and makeshift ORs.

Working in an Ebola treatment center in West Africa

Later, during the Ebola crisis, Dr. Kramer deployed with Samaritan’s Purse DART, serving in an Ebola treatment unit where the mortality rate was among the highest on Earth. He donned full PPE in punishing heat, cared for patients dying of hemorrhagic fever, and witnessed levels of human suffering that leave permanent marks on the soul. His slides show handwritten scripture and prayers scrawled on the walls of the unit, a testament to the spiritual weight of that environment.

His own lessons learned capture the character of his service:

• Be wary of burnout.

• Take care of each other.

• Always bring an ultrasound.

• Sometimes you need to sweep the floor because serving means doing whatever is needed.

These experiences did not harden him. They refined him.

Pokrovsk, Ukraine: A War Zone Without Illusion

This winter, Dr. Kramer volunteered with Frontline Medics on the Pokrovsk frontline in Ukraine. It is one thing to fly across the world for a short humanitarian experience. It is another to embed with a Ukrainian unit, take cover from incoming fire, stabilize mutilating trauma, and perform advanced anesthesia procedures in an environment defined by scarcity and threat.

This is what he did.

He provided ultrasound-guided regional anesthesia. He placed central lines. He secured airways. He stabilized the wounded until they could be evacuated. These are the same skills we teach our DNAP residents. In Ukraine, he used them to keep people alive in a war zone.

His purpose never wavered. His faith never wavered. His call to serve never wavered.

This Is What Nurse Anesthesiology Looks Like at Its Best

Nurse anesthesiology exists because of clinicians who step into places others will not. Rural hospitals. Underserved communities. International humanitarian missions. And sometimes, active war. These are the environments where the profession proves its value without debate.

Dr. Kramer embodies the best of this profession. He is skilled, humble, unflinching, and unselfish. He represents the clinician you want at your back when everything goes wrong. He also represents the educator you want shaping the next generation of nurse anesthesiologists.

He does not just teach servant leadership. He lives it.

Supporting the Work

Frontline Medics relies on donations to supply and staff their stabilization teams. Their operational fund is tax-deductible and available here:

https://donorbox.org/fm-lifeblood

The Best of Us

Every program has at least one faculty member who defines its culture. At National University’s DNAP program, that person is Dr. Eric Kramer. He is a clinician of immense skill and a teacher of uncommon humility. More than anything, he is a man who lives out the values our profession claims to hold.

He remains the best of us and I am unbelievably proud to call him my colleague and friend.

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The first CRNA job people choose is almost never the job they actually needed. Every year I meet new graduate CRNAs who are navigating their first job search, optimistic, proud, and ready for the next phase. And every year, I watch many of them make the same predictable mistake:

They end up clinically underutilized, professionally diminished, geographically unhappy, or questioning whether they picked the wrong field entirely.

None of this is random it’s a pattern I’ve seen for years.

Across years of program leadership, recruitment work, contract negotiations, and clinical group management, the same reality emerges again and again:

Everything else is noise. Three factors determine whether you thrive or burn out.

I call them the CRNA Happiness Triangle.

These three factors form the CRNA Happiness Triangle, your blueprint for evaluating any job offer.

The CRNA Happiness Triangle

The three corners that define CRNA job satisfaction:

Corner 1: Pay, Vacation, & Benefits

Corner 2: Location (Where Your Life Happens)

Corner 3: Autonomy & Professional Respect (Who You’re Allowed to Be at Work)

Each corner tells a different truth about your career. If even one collapses, the job won’t last. If two collapse, you’ll be looking for the exit by the end of the first year.

When all three align, new grads thrive.

Corner One: Pay, Vacation, and Benefits - The Seductive Corner

This is the corner new grads chase hardest. Employers know it. Recruiters know it. Hospitals know it.

Salary is shiny. PTO feels like freedom. Benefits feel adult and stable.

But here’s the truth the early-career data keeps screaming:

• Salary is the easiest part for employers to manipulate.

• Time off often determines happiness far more than base salary.

• Benefits can represent massive buried value, or a hidden liability.

• Some jobs advertise high pay, but the true highest-paying roles, outside of temporary locums spikes, are usually those with greater autonomy or independent CRNA practice.

And the biggest trap:

Pay matters. But it does not anchor long-term satisfaction. At best, it enhances the other corners. At worst, it blinds you to them.

Corner Two: Location - The Corner New Grads Underestimate Until It Hurts

Location deserves its own corner because it governs something bigger than your job: Your life.

Location is about:

• Whether you want to live in the community

• Commute tolerability

• Weather patterns that shape your daily routine

• Family/partner happiness

• Cost of living, safety & support systems

• The ability to build a real life outside the hospital

If you don’t want to live somewhere, you won’t stay there. No salary can change that.

Burnout literature confirms this repeatedly: Environment, social support, community integration, and lifestyle stability matter as much as, if not more than, professional factors.

New grads discount this corner the most.

Experienced CRNAs discount it the least.

Corner Three: Autonomy & Professional Respect - The Clinical Identity Corner

This corner defines who you get to be as a CRNA. Autonomy and respect aren’t perks, they are the oxygen of professional identity. And while many new graduates underestimate this corner, mid-career CRNAs consistently say it is the one that matters most.

Autonomy is what you’re allowed to do.

Respect is how your judgment is treated.

Together, they form the professional climate you work in every day, and they show up, powerfully or painfully, in three major practice environments:

1. Independent practice, where CRNAs manage the anesthetic from evaluation to emergence, make real-time decisions, handle complications, and grow rapidly. These clinicians consistently report the strongest professional identity and the broadest long-term mobility.

2. High-trust collaborative models, where physician anesthesiologists value CRNA autonomy and clinical judgment. CRNAs practice at or near full scope, develop advanced problem-solving skills, and experience the psychological safety required for real growth. When these teams exist, they produce exceptional clinicians.

3. Micromanaged or restrictive environments, where CRNAs are relegated to “technician” roles and clinical judgment is often overridden. These jobs may look attractive, big hospitals, name recognition, locum pay, but they carry a hidden long-term cost: CRNAs in these settings may not develop the independence needed to compete for better roles later. Many eventually feel stuck, unhappy, and unsure if they can safely transition out.

Autonomy and respect define not just how cases run, but how you see yourself. You feel it in how surgeons speak to you, whether nursing teams treat you as a leader or a task-doer, and whether your clinical judgment is trusted. You feel it in the micro-moments: the absence of micromanagement, the presence of clinical voice, the expectation that you will handle complexity, not be shielded from it.

Autonomy also protects you in a market downturn.

When budgets tighten, hiring freezes, and groups consolidate, the CRNAs who remain in highest demand are the ones who can function independently and manage a wide range of cases without supervision. High-autonomy clinicians increase a system’s flexibility and reduce staffing risk, they are the last to be cut and the first to be hired.

CRNAs who trained in restrictive environments often learn this the hard way. When the market tightens, limited scope becomes limited opportunity. Autonomy isn’t just professional identity. It’s economic protection.

Make the career decisions now that build the independence you’ll rely on later.

When this corner is strong, CRNAs stay, even when pay is average.
When it is weak, they leave, even when pay is exceptional.

CRNAs who begin in high-trust or independent environments progress faster, negotiate better, and enjoy broader opportunities. Those who start in restrictive systems often find themselves in a clinical cul-de-sac: lower pay (because the market pays less for roles with minimal decisional responsibility), low autonomy, limited future mobility, and rising dissatisfaction.

Here’s what most new grads don’t realize: the highest-autonomy jobs, especially independent and high-trust collaborative models, also tend to have the highest earning potential. Markets reward responsibility. The more decisional authority you carry, the more your long-term earning power grows.

This corner is not just about your first job. It can determine the next ten.

The Reality Check Every New Grad Needs

Let’s say it plainly:

You spend more hours at work than anywhere else in your life except sleeping.

More than with your partner.

More than with your children.

More than in your home.

So one truth rises above everything else:

You cannot out-earn toxicity.

You cannot out-PTO disrespect.

You cannot location-hack micromanagement.

Happiness isn’t a luxury in anesthesia, it’s a retention strategy.

How the Triangle Behaves in Real Life

Every job is a tradeoff. But the smartest tradeoffs follow predictable rules:

High Pay + Bad Location + Low Autonomy/Respect

You will leave. Fast. And it’s worth noting: this combination is actually rare. The highest-paying permanent jobs are usually in places with more autonomy, not less. When high pay appears in low-autonomy settings, it is often a temporary market distortion, usually locums rates that normalize once the staffing shortage resolves.

Moderate Pay + Great Location + Strong Autonomy/Respect

You will grow, and excel. These jobs build skill, confidence, and future mobility. Many of the strongest long-term CRNA careers begin here.

High Pay + Great Location + Poor Autonomy/Respect

You’ll last slightly longer, but you’ll erode from the inside, every single day. High pay and a desirable city cannot compensate for being undervalued or micromanaged.

Strong Autonomy/Respect + Good Location + Acceptable Pay

This is where the happiest CRNAs live, where careers accelerate - not stall, and where many ultimately earn the most over the course of a career. Markets reward responsibility. The more autonomy you carry, the more leverage and earning power you build.

What New Grads Should Do Right Now

Before signing anything:

1. Rank the three corners for your current life stage.

2. Identify the corner you refuse to compromise on.

3. Ask explicit questions about autonomy, respect, and culture - don’t assume.

4. Interview the location as seriously as you interview the job.

5. Choose the job that builds the CRNA you want to be five years from now.

Your first job is not your forever job, but it will shape who you become. Choose the job that builds the clinician you want to be.

Working CRNAs your answer helps new grads more than you think.
What mattered most to you, and what did you wish you had prioritized?

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TL;DR: In today’s tighter reimbursement environment, anesthesia’s value is measured by the revenue and efficiency gains it enables. This piece explains why CRNAs and anesthesiologists must understand their ROI, adapt their skills and embrace team‑oriented behaviors to thrive.

It’s time to reframe the conversation.

“Know your worth” has emotional appeal. But in today’s healthcare economy, it’s not enough. If we want to advocate, and survive, we must think and speak in the language decision-makers use: return on investment.

For years, that mantra has echoed across anesthesia forums. It’s well-intentioned. But in hospital finance, “worth” is subjective. ROI is measurable, actionable, persuasive.

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Then → Now: ROI Redefined

Ten years ago, anesthesia professionals, whether CRNAs, physician anesthesiologists, or anesthesia assistants, were often compensated below the revenue they generated directly. CMS reimbursements were higher, commercial rates more negotiable and hospitals more financially comfortable. Today, reimbursement is tighter, yet our work enables greater facility revenue than ever before. This article explains why understanding and demonstrating your ROI is essential.

Fast forward to today, and the equation has changed. The ROI of anesthesia is no longer about professional fees; it’s about what anesthesia enables. ROI (Return on Investment) = (Benefits – Costs) / Costs.

• That ISB that nets ~$60 in pro fee? It unlocks hundreds in facility revenue when we perform it.

• That CMS-funded TKA might pay us $300, but the hospital sees $14,000+ on the full case.

We don’t “own” that revenue, but without anesthesia, it doesn’t happen.

What Hospitals Already Know

Hospitals already pay large salaries to roles with low direct revenue, because of their strategic ROI:

• Primary Care earning $300k+ while an incredibly valuable service, often does not generate that much in professional fees, but their referrals drive revenue to imaging, lab, surgery, and subspecialties. According to a Merritt Hawkins 2019 survey, a typical PCP produces about $2.1 M/year in net hospital revenue, mostly through referrals, not direct practice income.

• RNs are not significant revenue generators, but without them, outcomes and throughput tank. Increased RN staffing improves mortality rates, decreases length of stay, and supports throughput efficiency and lead to cost savings of >$117M annually in Medicare patients.

• That ~$2M robot for lap choles + annual service contracts ($150–200k)? It doesn’t raise revenue per case, but it attracts the right surgeons to drive case volume and is used for marketing to the public.

One hospital CEO told me, over a decade ago: “Your anesthesia pro fees fall between the seat cushions of this place’s budget.” It stuck with me because it’s true.

The value of anesthesia is in what it makes possible: enabling surgery, unlocking facility revenue, retaining high-value surgeons, and protecting throughput.

Market Signals Are Clear

Despite reimbursement cuts and consolidation pressures, the market keeps signaling that anesthesia is ROI-positive:

• Facilities pay for physician anesthesiologists and CRNAs based on perceived strategic value. Strategic Value Drives Compensation.

• Locum rates remain high due to supply-demand imbalance.

• ORs are staffed to meet surgeon demand, not anesthesia budget ceilings.

If anesthesia weren’t ROI-positive, hospitals would shrink OR footprints, cut service lines, and automate away our roles. Instead, the market keeps leaning toward us, for now.

Beyond Numbers: The ROI of Attitude

While locum rates and block utilization metrics tell part of the story, administrators also notice how providers collaborate. A CRNA or anesthesiologist who anticipates the surgeon’s needs, pitches in during turnovers and keeps the focus on patient outcomes creates smoother workflows and happier teams. Conversely, providers with a “me‑first” mentality can slow the OR and erode goodwill. In an era of lean staffing, being a reliable team player is itself a form of ROI.

Policy Wildcards: The OBBB Threat

Regardless of political stance, these are fiscal realities that will shape hospital margins. No ROI model exists in a vacuum. Legislation like the One Big Beautiful Bill (OBBB / H.R. 1) introduces macro threats that could reshape hospital margins, and our value.

Key impacts already emerging:

• Cuts to Medicaid & eligibility tightening: The bill reduces federal Medicaid spending and imposes stricter eligibility, potentially causing millions to lose coverage.

• Uncompensated care surge: Hospitals may absorb greater burdens if coverage slips.

• Rural & safety-net strain: Already thin margins make these hospitals especially vulnerable to cuts.

• Tight capital & staffing budgets: To preserve core missions, hospitals may delay expansions, thin staff, or shutdown less profitable services.

These shifts underscore that ROI is not just about your individual skills today, but about how the economics around you evolve. Those of us in anesthesia must be increasingly proactive in demonstrating value, both for today and in a more constrained policy environment.

But ROI Isn’t Static

This environment is fragile. As healthcare margins tighten, so will the tolerance for inefficiency.

• A drop in Medicaid enrollment or facility subsidies will hit safety-net hospitals (and most facilities) hard.

• Lower margins will eventually mean surgeon convenience will no longer drive block time.

• Expect tightened OR scheduling, consolidated rooms, and leaner staffing with an ‘all hands on deck’ approach to provider utilization and SOP, regardless of degree.

When that happens, the market won’t reward titles, it will reward performance.

Professionals who:

• Perform regional and advanced skills

• Manage complex and high-acuity cases

• Practice independently or in lean teams

• Adapt to off-hours and remote sites

• Not have the “shift-work” mentality

…will remain highly valuable. Those who define their role narrowly, or resist adaptability, will see their ROI, and job security, slip.

The ROI Imperative

Ultimately, knowing your ROI means more than knowing your pay. It means understanding how your skills, adaptability and attitude contribute to the hospital’s success. Providers who perform advanced techniques, collaborate seamlessly and keep patient outcomes at the center will remain indispensable, even as reimbursement models evolve.

So yes, know your worth. But more importantly?

Know your ROI. And make sure you’re always on the right side of it.

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