An Open Letter to the ALANA Membership
Jeffrey S. Plagenhoef, M.D.

An article recently published in the February, 2008, issue of the ASA Newsletter has unintentionally offended some nurse anesthetists. Most objections forwarded have not challenged the factual content of the article, but rather have found fault with semantics and abbreviations therein. I would like to apologize for this unintended consequence, as there was no deliberate malice or disrespect intended. As a simple apology would do nothing to cause anyone to consider an alternative viewpoint, I would also like to explain why this article was published and why particular words and abbreviations were used.

One duty expected from ASA Committee Chairs is communication. To that end, committee chairpersons are asked annually to write at least one ASA Newsletter article serving as an update of their committee’s work. In the case of the Committee on the Anesthesia Care Team (CACT), the most significant new work product approved by the ASA House of Delegates last year was a document objectively outlining similarities and differences between anesthesiologist assistants’ and nurse anesthetists’ prerequisites to postgraduate education, didactic and clinical training and their subsequent practice.                        
 
The need for this document has truly been the direct result of the impact of testimony made by nurse anesthetists against anesthesiologist assistants. I say that to help you understand, NOT to stir any pot. This statement simply reflects the historical truth. Please do not blame me for history! Over several decades, every time attempts are made by anesthesiologist assistants to gain licensure in a new state, negative testimony against their quality and safety is brought forward. This is no more acceptable to the CACT than if the reverse were true.  The CACT did not decide who is and is not officially defined as part of the anesthesia care team (ACT), but the ACT was created to support and act in the best interest of the entire care team and the patients it serves. Anesthesiologist assistants (AAs) have been part of the ACT since the early 1970's, although they have only been licensed in Alabama since the mid-1990’s. The Alabama State Society of Anesthesiologists (ASSA) supports both non-physician members of the ACT. Nurse anesthetists’ negative opinions toward the other non-physician member of the ACT is likely created by reading and hearing the anti-AA position repeatedly projected by the American Association of Nurse Anesthetists (AANA). Attempting to be objective and fair, the CACT was asked by the President of the American Society of Anesthesiologists to investigate and report on the degree of validity of testimony made for and against AAs. This was the reason for the article, and the conclusion is that available literature does not support the arguments against AAs.

After roughly ten years of experience communicating with lay people on issues relating to health care in general and the ACT in particular, a few problems have become obvious to me. One frequent impediment to successful communication seems to be the “alphabet soup” created by the multiple types of care givers (ex., in the OR arena alone we have: M.D., D.O., DMD, DDS, LPN, RN [2 or 4yr], BSN, CST, CNOR, RNFA, CPAN, CNM, CNS, CRNP, CRNA, AA-C). Most of us who work in the OR cannot state the differences in education, job description or scope of practice of each of these abbreviated titles, and the confusion created by all the letters after names leaves the average lay person scratching their spinning head. That understood, I and many others have agreed to simplify verbiage and descriptions as much as possible when dialogue relates to issues that apparently can confuse even those directly involved, particularly if lay people are a significant part of the target audience. In this instance, people outside of anesthesia are very much part of the intended audience.

In the case of the registered, board eligible, board certified, certified, credentialed, etc., these words are typically not used to address each other in the work place. While individual attainment of such levels of training are very important in Departments of Human Resources and Medical Staff Offices for the purposes of hiring, credentialing and determination of pay scales, they serve less purpose in the clinical realm. It is very reasonable to assume that every nurse anesthetist working in our hospital is both certified and registered, otherwise they would not be employed in that capacity. We say, for instance, doctor, nurse, nurse anesthetist, scrub tech, first assistant, PACU nurse. I have never heard someone say, “I need a certified and registered nurse anesthetist to help get the next case going.” We shorten to nurse anesthetist, and I have never heard a complaint about that until now…never!

We call the most highly trained and skilled nurses within nursing “nurse anesthetists.” The national organization that represents them is called the American Association of Nurse Anesthetists, and that organization is not criticized for failing to be the American Association of Certified Registered Nurse Anesthetists. Note also that when the organization is referred to with its proper abbreviation, AANA, those that use that abbreviation are not criticized for failure to add the “CR” to make it AACRNA.

Also note that within Alabama, where feelings have been hurt by use of “NA,” nurse anesthetists chose to create a state organization and call it the Alabama Association of Nurse Anesthetists leaving out both the distinctions of “certified” and “registered.” Note additionally that they did not for the sake of greater respect or recognition of accomplishment of its members select to abbreviate it ALACRNA, but rather they use ALANA. Is it not somewhat contradictory to disapprove of those outside of your circles using the same words and abbreviations that you use yourselves?

The ASSA is told that this particular issue is the main focus of objections raised in the case of the ASA Newsletter article. “Nurse Anesthetist” was abbreviated properly to “NA” and offense was taken that “CRNA” was not used instead. For the sake of simplicity and clarity in communication, my committee chose to avoid both AA-C and CRNA in the Statement on this subject and in the article. Neither category of provider got recognition for their certification accomplishment in the article – fair and balanced. Both groups were treated equally. Of worthy note, I have not read anything from the AANA regarding anesthesiologist assistants that used AA-C, their proper official abbreviation to indicate that they too earn certification. Should that not be considered an identical offense? The terms certified and registered have nothing to do with the issues addressed in the article and would have only added confusion and unconstructive wordiness. Simple and concise was the goal, not to offend or demean.

As a result of this article, it has been pointed out that my use of “NA” in the article caused some readers to believe that I was intentionally being derogatory and subtly comparing nurse anesthetists to nursing assistants. For reference, the first sentence of the article in question uses the accepted rules for abbreviating words or strings of words that would, if written out, make an article wordy: “…Do differences in the education and practice of anesthesiologist assistants (AA) and nurse anesthetists (NA) indicate the superiority of one profession over the other…” I had never heard of this category of provider, or their “NA” title, until the President of ALANA explained this to me. Someone suggested that the use of “NA” could have caused a reader to think that the author was referring to “nursing assistant,” which led to their false accusation that I was actually intending to obfuscate the difference between the two categories of providers. Reference the comments above regarding the confusion created by the alphabet soup. If one really thinks that a reader might confuse the most trained nurse with the least trained because of the referenced use of “NA,” is it really unreasonable to expect readers to upon getting mixed up refer back to the first sentence they read that defines the abbreviation?

I fully support and continually defend the anesthesia care team, and to me the ACT has always included nurse anesthetists. I routinely brag on the quality, skill and contribution to the ACT made by nurse anesthetists. I fully acknowledge the significant contributions nurse anesthetists make to the American health care system. If this were not so, I would not have practiced with them within the ACT for 17 years. I am an intellectually honest man; if I did not trust and respect the skills of nurse anesthetists, I would not have made the professional decision to work with them. Thanks to each and every one of the Alabama nurse anesthetists for jobs well done. I continue to call for our constructive collaboration on the many issues we both regard as important. We are stronger working unified!

I wish to thank Shannon Scaturro, President of ALANA for his professionalism and willingness to discuss this sensitive issue. He represents the organization with class!

Very sincerely,

Jeffrey S. Plagenhoef, M.D.
President ACMG
ASA Director, Alabama
Chair, ASA Committee on the ACT

An Open Letter to the ALANA Membership:
ALANA Responds to Article in ASA NewsBulletin

Dr. Jeff Plagenhoef's Letter to the ALANA Membership

ALANA Responds to Dr. Plagenhoef's Letter

Comparison of CRNAs and AAs