The debate over how anesthesiologists and CRNAs should work together is growing louder, and more urgent. With anesthesia workforce shortages widening, reimbursement pressures mounting and access to care gaps deepening, leaders across the field shared their vision for how the relationship between the two professions should evolve over the next decade.
Editor’s note: Responses have been lightly edited for clarity and length.
Question: How do you think the relationship between anesthesiologists and CRNAs should evolve over the next decade?
Rita Agarwal, MD. Clinical Professor of Anesthesiology at Stanford (Calif.) University: I believe in the team model and physician-led care. I have worked on and off with both CRNAs and CAAs and have genuinely enjoyed our interactions. I also do my own cases over 50% of the time and have worked with trainees. There is room for the evolution of roles with increased AI-guided protocols and telehealth capabilities, but I will never stop believing that every patient deserves an anesthesiologist, physician or dentist, as part of their care.
Dee Berry DNAP, CRNA. Immediate Past President of the Michigan Association of Nurse Anesthetists: I believe the relationship should evolve toward true professional respect, with both CRNAs and anesthesiologists practicing to the full extent of their training and licensure. That also means being willing to move beyond traditional, title-based hierarchies and focusing instead on what actually drives the best patient outcomes. Care should be genuinely patient-centered where the provider whose skills best match the case is the one delivering the anesthetic.
That’s not always a comfortable conversation, but it’s an important one. Decisions should be guided by safety, outcomes and system performance, not simply degree or historical structure. I also think both groups are stronger when we stop framing the relationship as a competition and start aligning on shared challenges, especially anesthesia reimbursement, access to care and workforce sustainability. A unified approach there makes the entire field more effective. Ultimately, the future should be defined by mutual respect, accountability to outcomes and a shared commitment to doing what’s best for patients.
Mark Blazey, DNP, MSN, CRNA. Immediate Past President of the New York State Association of Nurse Anesthetists: The outdated, often friction-filled hierarchy must evolve into a highly coordinated, economically viable partnership where physicians and CRNAs work in adjacent operating spaces, rather than stacking and duplicating resources.
Instead of a single, rigid standard, this relationship should be adaptive and driven by geography and institutional economics, prioritizing patient access over reimbursement. In the coming years, this may mean a collaborative team care model in metro centers and completely autonomous practice in rural systems.
Katy Dean, CRNA. TKMAnesthesia (Newport News, Va.): The relationship between anesthesiologists and CRNAs should evolve toward a more collaborative, patient-centered model that utilizes each provider at the highest level of their education, training and clinical competency. The traditional Medicare medical direction model should be reevaluated and phased out, its rigid supervision ratios don’t reflect patient acuity, provider experience or anesthetic complexity. In many settings, particularly ASCs, rural hospitals and underserved communities, CRNAs are fully capable of providing safe, high-quality care independently, and staffing decisions should reflect patient complexity and institutional needs rather than fixed regulatory ratios.
Ultimately, anesthesiologists and CRNAs should work as true colleagues, each contributing their unique strengths. In higher-acuity cases, physician anesthesiologists may play a more direct consultative or supervisory role while CRNAs manage many anesthetics autonomously, a competency-based approach that would improve efficiency, expand access and ensure patients receive safe, evidence-based anesthesia from the most appropriate provider for their needs.
Megan Friedman, DO. Chair and Medical Director at Pacific Coast Anesthesia Consultants (Los Angeles): Over the next decade, the conversation should move away from professional turf debates and toward building high-functioning perioperative teams focused on shared operational goals. With declining reimbursement and increasing demand for anesthesia services, anesthesiologists and CRNAs should continue working together with mutual respect and a common focus on improving efficiency, optimizing resource utilization and supporting health systems in delivering safe, timely care. The strongest models will be those that align teams around patient outcomes and operational performance.
Joseph Hall, CRNA. Upper Cumberland Anesthesia Associates (Cookeville, Tenn.): The adversarial relationship that has historically existed between anesthesiologists and CRNAs needs to turn more collegial with the focus changing to the preservation and/or maximization of reimbursement. Depending on payer mix, both specialties require stipends in order to meet salary demands, and it doesn’t take a rocket scientist to figure out that is not sustainable long term.
Lisa Howse, CRNA. US Anesthesia Partners of Texas (Dallas): CRNAs should be given total autonomy at the full level of their training and expertise in all states. If the CRNA prefers to work collaboratively with an MDA or CRNA group, then that is the CRNA’s choice. It should not be a restrictive requirement. Anesthesiology assistants need to be utilized with extreme caution, if at all.
J. Mark Hylton, Jr., MD. Clinical Assistant Professor and Anesthesiologist at UNC Anesthesiology at UNC Wayne (Goldsboro, N.C.): Over the next decade, which will be my prime years of practicing anesthesiology, I believe the relationship between anesthesiologists and CRNAs will continue to evolve into highly collaborative care teams where our education, training and skillsets will complement each other to tackle the growing demands for anesthesia services.
We will continue to see collaborative efforts in OR and non-OR management to optimize procedural utilization and efficiency, improve patient safety and provide high-quality perioperative care. When politics are left at the door and patients are the priority, what we should see is a strong, collaborative relationship where Anesthesiologists, CRNAs and CAAs leverage their respective expertise to provide high-quality anesthesia care to the patients in their community.
Bob Johnstone, MD. Professor and Chair for the Department of Anesthesiology at West Virginia University (Morgantown): Anesthesiologists and nurse anesthetists should, and probably will, grow closer together. I see much collaboration and socialization across the specialty today, from jointly attending grand rounds to serving on committees and sharing stories in break rooms. Ultimately, it is about patient care, and there are opportunities for everyone to improve safety and efficiency. I served on the American Association of Nurse Anesthesiology Committee on Certification years ago and have published articles with CRNAs as co-authors. I learned from my co-authors and value the friendships that developed. People will see that we all gain when we work and grow together.
Denis Jones MSN, CRNA. American Anesthesiology Associates of IL (Mokena, Ill.): The relationship between anesthesiologist MDs and CRNAs has historically been contentious, but there is room for both, and both are needed to meet projected demand. Militants exist on either end, but most clinicians sit in the middle and work together with little conflict beyond the usual workplace differences.
The economics of anesthesia has forced a new business model that can no longer rely on past practices: every clinician must be in a room doing cases individually. The days of “supervising” multiple rooms are over. Surgeons can tell strong anesthetists from weak ones, MDA or CRNA, and are indifferent so long as they have a stable surgical platform. Both must stay current with advancing pharmacology, techniques and best practices to remain credible members of the team.
A collegial relationship isn’t hard to achieve when both sides are respectful and civil. Only when the “us versus them” mentality is abandoned will conflicts abate, and we can get on with delivering safe, compassionate anesthesia for the surgeons and patients we serve.
C.J. Kucik, MD. Professor of Anesthesiology and Pain Medicine at University of Washington School of Medicine (Seattle): Over the next decade, I believe the relationship between anesthesiologists and CRNAs should continue to evolve toward more cohesive, standardized, physician-led anesthesia care teams that extend the reach of both physicians and advanced practice nurses. When these teams function with clear roles, shared expectations and strong communication, they allow us to serve more patients, expand access to anesthesia care, decrease costs and improve patient safety.
As surgical patients become increasingly medically complex, the future of anesthesia care should focus on building highly reliable teams that leverage the education, training and expertise of each profession in a coordinated model centered on the patient.
Anthony Lawson, MD. CMO of Quantum Anesthesia Services (Chicago): My perspective differs from most anesthesiologists. I began my career in the Navy, where physicians and nurses worked in tandem. The physician-nurse relationship shouldn’t be adversarial. CRNA organizations need to stop saying CRNAs are a more economical value, because reimbursements are made by unit-charge, not provider. Anesthesiologist organizations need to stop fronting as if all care requires a physician.
Leonard Lind, MD. Professor Emeritus of Anesthesiology at University of Cincinnati College of Medicine: The relationship must evolve; however, the CRNAs appear to be moving towards totally independent practice. I think most are well trained and can clearly handle most cases. For large traumas, transplants and cardiothoracic, I am not sure. If they practice independently, they must assume all malpractice risk and introduce themselves as nurse anesthesia providers, not as “doctor“ even if they have a doctorate in nursing practice or a PhD. There will never be enough anesthesiologists and there will always be room for non-MD providers.
Michael Nurok, MD, PhD. Professor and Co-Chair in the Department of Anesthesiology at Cedars-Sinai Medical Center (Los Angeles): In view of the shortage of anesthesia caregivers, our delivery systems and national societies need to evolve and develop models that match patient care needs to anesthesia caregiver skills. Doing so will require less focus on caregiver training pathways and more focus on how competently individuals can provide care for a specific procedure.
Mary Peterson, MD. Executive Vice President and Chief Operating Officer of Driscoll Health System (Corpus Christi, Texas): The vast majority of the nation’s healthcare facilities use the care team model where anesthesiologists, nurse anesthetists, anesthesiology assistants and anesthesiology residents work together in harmony. The teams I work with enjoy working together, respect each other and have close relationships throughout our tenure together, which sometimes spans decades.
Although we are at a point where our success has led to a demand/supply imbalance, training programs for physician anesthesiologists, nurse anesthetists and anesthesiology assistants are increasing class sizes to meet this demand. At the same time, anesthesia groups are working hard to recruit and retain all of these professionals. Retention requires a professional and collegial workplace. In 10 years from now, I believe we will have worked through the increased demand for our services, navigated the rapidly changing needs of the patients and organizations we serve, and will continue to work cordially together in the care team model because it is the safest for our patients.
Michelle Reilly, DNP, CRNA. Chief CRNA, Anesthesia Co.-Frederick Division at Frederick (Md.) Health: Over the next decade, the relationship between physician anesthesiologists and CRNAs should continue evolving away from hierarchy-based thinking and toward true professional collaboration built on mutual respect. Both CRNAs and physician anesthesiologists bring valuable clinical expertise, critical thinking, perioperative leadership and patient advocacy to anesthesia care, with each profession contributing unique training and perspectives that strengthen the team. The strongest departments will be the ones that utilize both professions appropriately to tackle workforce shortages, operational pressures and declining reimbursement, with the focus remaining on patient care and access, not turf wars.
Jacob Schaff, MD. Division Chief of Cardiac Anesthesiology at White Plains (N.Y.) Hospital: The conversation about anesthesiologists and CRNAs needs to move from labor arbitrage to clinical design. The right design lets both professions practice more fully, not less. Physician anesthesiologists anchor perioperative medicine: pre-op optimization, quaternary care and the system-level work of making surgical episodes safer. CRNAs bring the clinical expertise in anesthesia delivery that keeps modern surgical care moving. The health systems that build teams around those distinct clinical strengths, rather than treating either profession as a substitutable input, will be the ones patients seek out and clinicians want to work in.
Nanette Schwann, MD. Professor and Vice Chair in the Research Department of Anesthesiology at Lehigh Valley Health Network (Allentown, Pa.): Every provider who can deliver safe anesthetic care should be doing so at the top of their license. The staffing model should follow the patient’s risk profile, not the profession’s political interests. We don’t have enough people to argue about who gets to do the work, we need everyone working.