Scope Creep in Anesthesiology: Midlevel Expansion vs. Patient Safety

Introduction: In recent years, anesthesiology has faced significant “scope creep” – the expansion of practice by non-physician providers such as Certified Registered Nurse Anesthetists (CRNAs) and Anesthesiologist Assistants (AAs). These midlevel practitioners are seeking greater autonomy, with some even adopting titles like “nurse anesthesiologist,” blurring lines between physician anesthesiologists and nurses. This trend has triggered intense debate in the medical community. Physician anesthesiologists warn that independent anesthesia practice by midlevels could jeopardize patient safety, given the vast differences in training and expertise. Meanwhile, nursing organizations argue that CRNAs can safely deliver anesthesia care without direct physician oversight, citing workforce shortages and rural care needs. In this article, we take a physician advocacy-oriented and cautionary perspective on scope creep in anesthesiology – examining the current legislative landscape, hospital policies, safety data, and the positions of key organizations – and discuss what it means for the future of the specialty.

An anesthesiologist adjusts anesthesia equipment in the operating room. Anesthesiologists undergo rigorous medical training (including ~15,000 hours of clinical training) to manage anesthesia and critical care, far exceeding the 2,600 hours in nurse anesthetist programs. Advocates argue that this extensive training is essential for patient safety, especially in emergencies.

Legislative and Regulatory Changes Enabling Independent CRNA Practice

One of the most impactful aspects of scope creep in anesthesiology is the changing legislative and regulatory environment that governs who can administer anesthesia – and under what level of supervision. Across the United States, many state governments have revisited laws to expand CRNAs’ scope of practice. Some states now allow CRNAs to practice withoutphysician supervision, a shift that has accelerated in the past few years. Notably, 25 states have opted out of the federal Medicare rule requiring CRNA supervision, effectively permitting CRNAs to work independently for hospital anesthesia services. This opt-out mechanism, first introduced in 2001, gained momentum recently: for example, Massachusetts in 2021–2024 removed physician supervision requirements for CRNAs, granting them full practice authority under state law and formally opting out of the federal rule in 2024. Delaware and Colorado likewise opted out in 2023, joining states like Arizona, Oklahoma, and Michigan that did so in 2020–2022. In all of these cases, governors and legislatures decided to loosen anesthesia oversight rules, often under the rationale of increasing provider supply or aligning with broader “Full Practice Authority” for advanced practice nurses.

However, organized medicine has pushed back hard against these changes. The American Society of Anesthesiologists (ASA) “strongly opposes” opt-out policies, arguing they “put patients at risk” and represent a “failed policy experiment.” ASA points out that removing physician supervision “decreases patient safety in operating rooms” and does not reliably improve access to care or reduce costs. The American Medical Association (AMA) has similarly treated scope-of-practice expansions as a major threat. In 2023, the AMA and state medical societies helped defeat more than 100 state bills that sought to inappropriately expand non-physician scope of practice. This included proposals in states like Georgia, where in 2024 two Senate bills would have stripped the requirement for CRNAs to practice under a physician’s direction. The Georgia medical association, with AMA support, successfully stopped those bills – thus “preserving physician supervision of nurse anesthetists,” which the AMA called imperative for patient safety. Likewise in Oklahoma, a 2023 bill to allow nurse practitioners and other APRNs (including CRNAs) independent practice and prescribing was vetoed by the governor as a win for patient safety. These battles illustrate how physician advocates are mobilizing to keep anesthesia a physician-led service.

At the federal level, the scope creep debate has centered on the Veterans Health Administration and Medicare rules. During the COVID-19 pandemic, the Centers for Medicare & Medicaid Services (CMS) temporarily waived the physician supervision requirement for CRNAs, leaving supervision to hospital discretion in order to “free up” providers in crisis conditions. This emergency measure gave a taste of CRNA independence nationwide. Since then, CRNA organizations have lobbied to make such flexibility permanent. In March 2025, federal legislation was introduced (the “Ensuring Veterans Timely Access to Anesthesia Care Act of 2025”) that would mandate the VA health system to allow CRNAs to practice autonomously, essentially replacing the VA’s current physician-led anesthesia model with a nurse-only model. The ASA has come out forcefully against this bill. ASA President Dr. Donald Arnold warned it would “dismantle the VA’s proven team-based model of anesthesia care” and “lower the standard and quality of care for America’s Veterans.” He noted that veterans are often older and sicker with complex conditions (e.g. Agent Orange or burn pit exposure), and “the involvement of a medically educated and trained anesthesiologist in the care of these patients is absolutely critical” for managing the higher risks. The VA’s own research supports caution: a VA Quality Initiative study found it “could not discern whether more complex surgeries can be safely managed by CRNAs”, especially in smaller hospitals without optimal support systems. As Dr. Arnold put it, the current VA policy has “absolutely no rationale to change,” and the ASA is working with veterans’ groups to oppose any effort to replace physician anesthesiologists with nurses in VA facilities.

Importantly, the majority of states still formally require some physician involvement in anesthesia, but the trend is clearly toward expansion of CRNA autonomy. Even in states that haven’t changed laws, bills are introduced yearly to erode supervision. For instance, in early 2025 lawmakers in several states (including Virginia) moved forward bills to eliminate physician supervision of CRNAs. The Virginia proposal would allow CRNAs to practice independently, with only a nominal “consultation” requirement with a physician, podiatrist, or dentist under Board of Medicine/Nursing regulations. This aligns with broader efforts by nursing groups to attain Full Practice Authority for nurse anesthetists nationwide. As of 2023, more than half of U.S. states allow CRNAs to practice without physician oversight, and multiple others were considering similar legislation. The result is a patchwork: in some states, every anesthetic must be supervised by an actual anesthesiologist (or at least a surgeon or other physician), while in others CRNAs can operate solo by law. This legislative momentum has emboldened CRNAs to push the envelope of their practice – often to the alarm of anesthesiologist physicians.

Hospital Policies and Anesthesiologist Oversight in Jeopardy

Beyond statutes and regulations, hospital and administrative policies play a pivotal role in how anesthesia care is delivered – and they too are shifting in ways that reduce anesthesiologist oversight. Healthcare administrators under cost pressures are increasingly open to models that maximize the use of less-expensive providers. In anesthesia, this has led to a rise of CRNA-only staffing models, especially in ambulatory surgery centers (ASCs) and smaller hospitals. For example, many physician-owned ASCs (often run on tight budgets) have been moving away from the traditional anesthesiologist-led care team. “Most of the ASCs in my area are becoming CRNA-only,” observed one CRNA in Arkansas, noting that this trend “helps keep costs down” for the facility. Another anesthesia professor noted that surgery centers demand “streamlined workflows, cost-effective care and rapid patient turnover” – which is driving a transition toward CRNA-led models that align with financial objectives. Simply put, employing only nurse anesthetists (who command lower salaries than physician anesthesiologists) can boost an ASC’s bottom line. “When we look at the economics of reimbursement in the ASC, it just doesn’t often make sense to have a supervising physician anesthesiologist,” said this CRNA, reflecting the mindset of many outpatient centers.

Pressure to cut costs has also led some hospitals to stretch anesthesiologist oversight thinner. In the common “anesthesia care team” approach, one anesthesiologist may medically direct multiple CRNAs (federal rules allow up to 1 MD to 4 CRNAs for billing purposes). Some administrators have attempted to leverage this by having one anesthesiologist cover as many rooms as possible, or even leave CRNAs largely unsupervised with an on-call physician available only for emergencies. An unintended consequence is that critical moments can be missed – even a 1:2 supervision ratio showed lapses in timely availability of the anesthesiologist on about 35% of days in one study (according to an AANA communication). If ratios increase to 1:3 or 1:4, the anesthesiologist’s ability to provide hands-on help in each room is further strained. Anesthesiologists warn that these policies erode the safety net that physician expertise is supposed to provide in each anesthetizing location.

We are already seeing real-world safety red flags from lax oversight. In California – a state that opted out of the federal supervision rule – regulators recently cracked down on hospitals that allowed CRNAs too much autonomy. In 2024, the California Department of Public Health cited two hospitals for CRNAs acting beyond their scope, after incidents where patients were harmed. In one case, a CRNA unilaterally changed a physician’s order (switching a patient’s anesthesia plan from general anesthesia to a spinal block, deemed higher risk for that case) without physician approval. The patient became unresponsive after surgery, prompting an investigation. Overall, several patients at these facilities suffered adverse outcomes and had to be transferred to higher-level hospitals. The state issued “Immediate Jeopardy” violations and an All Facilities Letter clarifying the rules: CRNAs in California may only administer anesthesia that has been ordered by a licensed physician (or dentist, podiatrist, etc). The letter emphatically noted that CRNAs *“are not doctors, and are not allowed to practice medicine.” Essentially, even though California doesn’t require formal anesthesiologist supervision, the state drew a line that diagnosing, deciding, or changing an anesthesia plan is the practice of medicine – something a nurse anesthetist cannot do independently. The California Association of Nurse Anesthesiology (the CRNA organization) and the California Society of Anesthesiologists unsurprisingly had competing opinions on this matter. But for now, the state’s clarification has “quieted” the issue in California, ensuring that hospital policies must keep CRNAs under physician direction at least in the ordering of anesthesia. This example underscores the dangers when hospitals drift into unsupervised CRNA practice: as one legal commentary put it, these cases highlight “the danger of unqualified providers making decisions that should be left to fully qualified physicians.”Patients often assume a CRNA or NP is “just like a doctor,” not realizing the difference in training and oversight – and “as demonstrated in these California facilities, medical error can and does occur when APPs overstep.”

Another hospital-level issue is who controls the anesthesia department. In some institutions, especially where anesthesiologists are employed by or contracted to hospitals, administrators may implement policies affecting the anesthesia team’s composition and leadership. There are reports of private equity-backed anesthesia groups and large health systems opting to replace physician anesthesiologists with CRNAs for many cases, retaining only a few anesthesiologists to supervise or handle the highest-risk surgeries. This diminishes anesthesiologists’ control over standards of care. Additionally, some states allow surgeons or other physicians to supervise CRNAs in lieu of an anesthesiologist – a practice anesthesiologists consider far from ideal, since a busy surgeon cannot truly supervise anesthesia while focused on operating. The ASA warns that in the absence of a dedicated anesthesiologist, often “the only other medical professional in the OR with the education and training to perform these [anesthesia] services is the surgeon”, who already has their hands full. Surgeon-supervision models thus effectively mean CRNAs are making clinical decisions alone, something hospitals may resort to if no anesthesiologist is on staff. Anesthesiologists view these trends with alarm: administrative cost-cutting should not trump patient safety. As we saw, regulators in at least one state (CA) stepped in when hospitals crossed a line. The fear among anesthesiologist advocates is that without robust rules, hospitals elsewhere might gradually normalize CRNA-led anesthesia for even complex cases, until a tragedy occurs.

Safety, Quality, and Outcomes: Physician-Led Care vs. Independent Midlevel Care

A central question in the scope creep debate is whether anesthesiology care is safer and of higher quality when led by physicians as opposed to delivered by CRNAs practicing independently. Proponents of expanded CRNA scope claim that numerous studies show no difference in patient outcomes between anesthesia delivered by a CRNA and that by a physician anesthesiologist. Indeed, CRNA advocacy groups point to peer-reviewed research – including a Cochrane review and analyses of opt-out states – suggesting that CRNA-only care is as safe as the physician-led model. They highlight that CRNAs already administer over 50 million anesthetics each year in the U.S. and are the sole anesthesia providers in many rural areas, with no evidence of higher adverse event rates in those settings. As one CRNA leader quipped, given how many CRNAs practice independently today, “if we were unsafe and killing people, we would know it. Where are we stuffing the bodies?” The American Association of Nurse Anesthesiology (AANA) also emphasizes studies finding CRNA care to be “high-quality and cost-effective,” and notes that CRNAs often serve regions where physician anesthesiologists are in short supply. In their view, allowing CRNAs to practice to the top of their license can alleviate provider shortages without compromising safety or outcomes.

Physician anesthesiologists, however, strongly challenge the “no difference” narrative – pointing out critical nuances in the research and real-world practice that favor the physician-led model. First and foremost is the disparity in training and skills. The pathway to become an anesthesiologist (MD/DO) involves 4 years of medical school plus a minimum of 4 years of residency (and often fellowship subspecialization), during which physician trainees log around 15,000 hours of clinical training across all facets of medicine and anesthesia. In contrast, nurse anesthetists generally complete a 2–3 year graduate program (now usually a doctorate of nursing practice) focused on anesthesia, accumulating roughly 2,500–2,700 hours of clinical training. The physician’s training is nearly six times longer and far broader in scope. As the AMA describes, anesthesiologists take all the courses relevant to practicing medicine, learning to manage a patient’s overall care, handle complex medical conditions, and respond to emergencies – whereas nurse anesthetists’ education, while extensive in anesthesia techniques, does not encompass the full depth of medical problem-solving. Even as some nursing programs transition to awarding doctoral degrees, “no significant changes have been made to the number of formal clinical hours” required, meaning the experiential gap remains. This stark difference matters because anesthesia is more than a set of technical tasks; it’s about medical judgment, diagnosis of any issues that arise, and rescue management of crises or complications. Physician groups argue that a CRNA’s narrower training may suffice for routine cases under ideal conditions, but lacks the medical background to optimally manage high-risk situations or recognize subtler health issues. As ASA succinctly states, “nurse anesthetists’ nurse education and limited clinical training does not equal the medical education and training of a physician”, and they “are not trained in medical decision making [or] differential diagnoses” – areas that become critical when things don’t go as planned.

What do outcomes data say? The truth is, robust evidence directly comparing solo CRNA care to anesthesiologist care is not abundant – mainly because anesthesia care in the U.S. is very safe across the board, making differences hard to detect without huge sample sizes. That said, physician advocates highlight research that questions the supposed equivalence of CRNA care in certain contexts. For example, studies of “opt-out” states have found no improvement in access to surgical care or anesthesia services for patients in those states compared to states that retained physician supervision. This undermines a key justification for independent practice (improving access in rural areas), suggesting that removing anesthesiologists doesn’t magically increase case volumes or availability of care. As for safety, the Veterans Health Administration’s own analysis (QUERI, noted earlier) explicitly raised safety flags, unable to conclude that CRNAs could handle the most complex surgeries as safely as anesthesiologists in the VA setting. Some observational studies have shown no mortality difference in surgeries anesthetized by CRNAs vs. physicians, but these studies often include CRNAs working within an anesthesia team or compare only relatively low-risk procedures. There is concern that such studies do not capture what happens in scenarios where a patient has major complications or requires a critical medical decision – scenarios in which an anesthesiologist’s expertise can be lifesaving. Notably, surveys of patients strongly side with physician expertise: in one AMA survey, 91% of patients said a physician’s years of medical education and training are vital to optimal care, especially if a complication or emergency arises. Patients intuitively understand that when seconds count, having the most highly trained anesthesia professional in charge is preferable.

From a quality standpoint, the “gold standard” in anesthesia is widely considered to be the physician-led anesthesia care team. This model is overwhelmingly used at academic medical centers and top-ranked hospitals. According to ASA leadership, “the nation’s top-rated hospitals all employ the physician-led model; not a single one of these institutions allows nurse-only anesthesia care.” In fact, even though some states allow independent practice, “anesthesia without physician oversight is rare” in most populated areas – about 95% of the U.S. population lives in regions where physician-led, team-based anesthesia is the standard. The persistence of this model reflects an industry recognition that it provides a safety redundancy: the anesthesiologist functions as a perioperative physician, evaluating the patient preoperatively, managing anesthetic depth and vital signs in real time, and addressing any medical issues (cardiac events, difficult airways, unexpected bleeding, etc.) that may arise during or after surgery. Nurse anesthetists in a team play a critical role in vigilance and technical delivery of anesthesia, but the physician anesthesiologist oversees the medical management and is immediately available to step in for crises. Critics of CRNA-only practice argue that removing this safety layer is analogous to removing the pilot from the cockpit and leaving a trained co-pilot alone – the flight may usually go fine, but in a storm, you’d want the captain’s expertise at the helm.

It’s also worth noting that no healthcare system with outcomes as its top priority has deliberately chosen a nurse-only model for high acuity care. The U.S. anesthesia mortality rate has fallen to extremely low levels in the era of physician-led anesthesia. Anesthesiologists fear that as more facilities employ CRNA-only staffing for cost reasons, subtle increases in complications or near-misses may occur. We have already seen case reports of severe adverse events in situations where no anesthesiologist was immediately available – for instance, a patient in Texas who nearly died after a CRNA-administered epidural went awry, in a case lacking proper informed consent and anesthesiologist backup【26†L223-L231**]. While anecdotal, such cases highlight the real risks when less-trained providers work at the edge of their competency.

In summary, physician anesthesiologists maintain that the safest anesthesia care is physician-led, and they caution against extrapolating that CRNAs are interchangeable with anesthesiologists in all situations. High-quality anesthesia care isn’t just about keeping a patient asleep – it’s about being prepared for the worst. As one ASA official put it, “Removing physician supervision of anesthesia care makes no more sense than removing it from any other critical care location.” The training gap and the medical decision-making expertise of physicians are central to this argument. On the other hand, CRNAs counter that their track record in many rural hospitals and surgery centers stands on its own, and that outcome data have not shown inferiority. This debate over safety and quality is likely to continue as both sides interpret the evidence to support their position.

Advocacy and Opposition: ASA, AANA, AMA and Others Weigh In On Scope Creep In Anesthesiology

The struggle over scope of practice in anesthesiology has been prominently led by professional organizations on both sides. On one side are physician groups like the American Society of Anesthesiologists (ASA) (along with state anesthesiology societies and the broader physician community such as the AMA). On the other side are nurse organizations, chiefly the American Association of Nurse Anesthesiology (AANA) (formerly American Association of Nurse Anesthetists), and their state-level affiliates, advocating for CRNA autonomy. Each camp has been vocal in press releases, legislative hearings, and public campaigns.

ASA’s stance is unequivocal: anesthesia is the practice of medicine, and for patient safety it must remain physician-led. The ASA’s official policy statements emphasize that anesthesiologists – with their extensive medical training – should direct the anesthesia plan and team. ASA acknowledges CRNAs as “valued members of the anesthesia team,” but firmly rejects the idea that their training is sufficient for independent practice in all cases. In advocacy, ASA often highlights that surveys show patients want a physician in charge of their anesthesia care: patients assume (rightly, in most settings) that an “anesthesiologist” is a physician and expect that level of expertise. Thus, ASA campaigns for truth in advertising and transparency about who is providing care. For example, ASA partnered with the AMA Litigation Center to file an amicus brief in a New Hampshire Supreme Court case to ensure the title “anesthesiologist” remains exclusive to physicians. (The NH Supreme Court indeed sided with physicians and the state medical board on that matter.) Similarly, when the District of Columbia considered a rule to let CRNAs call themselves “nurse anesthesiologists,” the ASA and AMA strongly objected. The AMA CEO James Madara wrote to DC regulators that “anesthesiology is a physician specialty, and the title ‘anesthesiologist’ has always been used solely by physicians”, noting that DC law already reserves that term for licensed physicians. The letter argued that letting nurses use the title would “create unnecessary confusion for patients” without any benefit to public safety. Efforts like these are part of the AMA’s larger “Fight to Stop Scope Creep” initiative, which actively supports physician groups in lobbying against unsupervised practice expansions.

The ASA also engages in public awareness campaigns, such as Made for This Moment, to educate patients and policymakers about the anesthesiologist’s critical role. When nurse anesthetists argue that they provide equivalent care, ASA often counters by citing contrasting evidence or by questioning whether those studies considered the most challenging scenarios. For instance, ASA press releases have pointed out that the VA’s own quality research did notendorse a switch to nurse-only anesthesia and that the VA itself employs over 1,000 anesthesiologists with no current shortage (in fact, more CRNA vacancies than physician vacancies) – undermining claims that independent CRNAs are needed to fill a gap. The ASA President in 2025, Dr. Arnold, stressed, “Physician-led, team-based anesthesia care is the gold standard … ASA supports keeping the nurse-only model rare and preserving the physician-led model of care.” His predecessor in 2023 likewise stated that no top hospital uses a nurse-only model and that “physician-led care is the status quo … that safeguards patient safety.” The ASA and state societies routinely testify in state legislatures that CRNA-only bills are dangerous. For example, in New Hampshire an ASA letter regarding a proposed independent PA bill (similar principles at stake) bluntly called it “a dangerous bill” that would allow practicing medicine without physician involvement. Through its Scope of Practice Partnership (with AMA and others), ASA has even provided grants to state medical societies (like in Georgia) to help finance campaigns that successfully defeated CRNA expansion bills. In short, ASA frames its opposition as patient advocacy, not turf protection: they argue it’s about keeping patients safe from lesser-trained practitioners, not about hierarchy.

On the other side, the AANA and CRNA community have mounted an aggressive campaign to advance their scope and raise their profile. AANA officially rebranded itself as the American Association of Nurse Anesthesiology in 2021, explicitly to position CRNAs as practicing “anesthesiology” (a move ASA decried). The AANA’s messaging emphasizes that CRNAs have been safely providing anesthesia for decades, often in underserved areas, and that they are answer to staffing shortages. For instance, AANA points out that CRNAs make up 80–85% of the anesthesia providers in rural U.S. counties, and they often function as the sole anesthetist for surgeries, obstetric deliveries, and trauma stabilizations in those communities. They also highlight cost-effectiveness: a CRNA-centric model can deliver anesthesia care at lower cost to hospitals and payers, which AANA argues could translate to savings in healthcare. On safety, AANA frequently cites a 2010 Health Affairs study and others that found no increase in surgical mortality in states that opted out of physician supervision. The AANA has issued statements rebutting ASA’s safety claims, calling them “false” and pointing to “numerous peer-reviewed studies” demonstrating that CRNAs provide care that is as safe and high-quality as anesthesiologists’ care. They also underscore that nursing anesthesia education has advanced – today’s CRNAs must earn a doctorate (by 2025, entry-level CRNAs will be doctoral-prepared) – and that their clinical training includes intensive experiences in administering all types of anesthesia. From AANA’s perspective, restrictive supervision rules are less about safety and more about “physician turf” or outdated regulations. AANA often uses phrases like “practice to the full extent of their education and training” and argues that eliminating unnecessary physician oversight can improve access to anesthesia services, especially as demand for surgeries grows. They also push back on the title issue: some CRNAs do refer to themselves as “nurse anesthesiologist” informally, and AANA contends that this nomenclature properly recognizes their role in giving anesthesia (though AMA and ASA fiercely disagree, as noted).

The conflict between ASA and AANA sometimes spills into the public arena. Each side has published white papers and reports to bolster their case. For example, a 2023 Medicus Healthcare Solutions white paper (cited by Becker’s) highlighted that 75% of CRNAs surveyed were practicing with no physician oversight as of 2023 – a statistic implying that independent CRNA practice is already commonplace. The same report noted that more than half of states now allow full CRNA autonomy, implicitly supporting AANA’s stance that CRNAs are well-established providers. Meanwhile, the ASA references studies (often published in anesthesiology journals) that found opt-out states saw no increase in anesthesia availability for Medicare patients and that team-based models did not harm access. ASA also cites surveys in which patients overwhelmingly prefer physicians for their care and want clear identification of who is a doctor. The AMA has thrown its weight behind the physician side of this fight through its “Scope of Practice Partnership,” helping to fund and coordinate state-level lobbying and even litigation to uphold medical board authority over anesthesia. For instance, that New Hampshire Supreme Court case mentioned earlier involved whether the state nursing board could independently expand CRNA scope; the court ultimately sided with the state medical board and physicians in maintaining the distinction between the practice of medicine and nursing. The AMA’s Truth in Advertising campaign also targets the issue of non-physicians using physician terms or not clearly disclosing their qualifications. This has direct relevance to anesthesiology, given the “nurse anesthesiologist” title dispute and the need for patients to know if the person at the head of the table is an MD or not.

Other stakeholders have joined the fray as well. The American Medical Association (AMA) broadly opposes independent practice expansions for all non-physician providers (NPs, PAs, CRNAs alike) and has specifically backed anesthesiologists on issues like the title protection and supervision laws. The American Hospital Association and some hospital systems have taken positions based on their needs – rural hospitals often support CRNA autonomy to staff their ORs, while large academic hospitals support physician-led models. The American Association of Nurse Practitioners (AANP) and other APRN groups are allies to AANA, since the fight is seen as part of a bigger movement for APRN independence. Conversely, the American College of Surgeons and other physician specialties tend to side with ASA/AMA, emphasizing the importance of physician expertise in all critical care. Notably, the Veterans groups in the VA debate have been split: some veterans’ advocates want any provider who can help reduce wait times (thus favoring CRNA full practice in VA), while many veteran patients and organizations have echoed ASA’s safety concerns.

In sum, the public positions are polarized. ASA and AMA paint a cautionary picture – that allowing midlevel anesthesia providers to operate independently is a risky experiment that could lead to more preventable complications and a degradation of care standards. AANA and CRNAs, on the other hand, portray it as an evolution – that CRNAs are already safely doing the job in many places and should be empowered to do so everywhere, especially given provider shortages and cost containment needs. For those of us advocating from the physician perspective, the priority remains clear: patient safety and quality of care must come first, and we believe that is best served by physician-led anesthesia care.

Legal Challenges and Recent Policy Shifts

As scope-of-practice tensions escalate, some disputes have ended up in court or prompted high-profile policy reversals. We’ve touched on a few already – such as the New Hampshire Supreme Court ruling upholding the medical board’s authority over anesthesia practice. Another example occurred in California earlier in the 2010s: the governor’s 2009 decision to opt out of CRNA supervision requirements was challenged in court by physician groups. Although the legal challenge did not ultimately block the opt-out (courts found the governor acted within his rights), it exemplified the lengths to which anesthesiologists went to try to maintain supervision in a state with many rural areas. More recently, the DC “nurse anesthesiologist” title fight in 2024 was headed off not by a court but by regulatory comment – the AMA and ASA’s strong opposition likely contributed to DC deciding against allowing the misleading title (D.C. preserved the restriction that “anesthesiologist” = physician).

Meanwhile, new legislation regarding Anesthesiologist Assistants (AAs) has also been part of the scope conversation. AAs are certified professionals with a master’s degree who, by law, must practice under the direct supervision of an anesthesiologist. They effectively function similarly to physician extenders in anesthesia, performing tasks delegated by the anesthesiologist. Historically, not all states license AAs – and CRNA groups have often opposed their introduction, seeing AAs as encroaching on CRNA jobs or as a tactic by anesthesiologists to maintain control of anesthesia delivery. Recently, some states have moved to authorize AAs to help address anesthesia workforce needs. For example, Virginia’s legislature in 2025 passed a bill to license Certified Anesthesiologist Assistants (CAAs), which had been prohibited before. The bill enjoyed bipartisan support and backing from the Medical Society of Virginia, which explained that AAs work exclusively under anesthesiologist supervision and can help anesthesiologists safely care for more patients by handling routine tasks. The Virginia Society of Anesthesiologists noted that anesthesiology was “the only physician group without multiple choices of advanced practice providers” and welcomed AAs as a second category (besides CRNAs) to “extend our reach” while keeping care physician-led. As of 2025, about 20 states plus D.C. license AAs, and more are considering it. On the flip side, in states like New York and Tennessee, CRNA associations have lobbied to block AA licensure bills, arguing that AAs have less training than CRNAs and are unnecessary when CRNAs could fill any gaps. This has led to some contentious hearings where CRNAs and anesthesiologists find themselves oddly on the same side opposing AAs (CRNAs to avoid competition, anesthesiologists sometimes over scope concerns), while other anesthesiologists favor AAs as a way to maintain physician-led teams. Legal battles haven’t erupted over AAs as much as CRNAs, but the policy trend is that more states are warming to AAs to relieve staffing shortages – a development that keeps anesthesiologists in the loop and thus is generally supported by ASA.

One more recent policy shift worth noting is how state boards and agencies are weighing in. In some states, nursing boards have unilaterally tried to declare that CRNAs do not need physician oversight, leading to turf battles with medical boards. The Texas Board of Nursing, for instance, issued positions that CRNAs have independent authority to select and administer anesthesia, which the Texas Medical Board did not fully agree with – such conflicts sometimes require legislative clarification. The Litigation Center of AMA has been involved in a few cases to support medical boards maintaining oversight on anesthesia-related practices. The outcome of these legal/policy skirmishes has generally favored physician oversight when patient safety is at stake, but it often takes concerted advocacy to reach that result.

Finally, we have to acknowledge the role of executive orders and temporary waivers, which can quickly change scope rules. During COVID-19, as mentioned, several governors issued emergency orders allowing CRNAs to practice without supervision in order to boost ICU procedure capacity. While most of those orders were temporary, in some states they paved the way for permanent changes once policymakers saw CRNAs working solo without immediate catastrophe. For example, in **Massachusetts, after a temporary COVID waiver, the policy momentum helped pass the 2021 law granting full practice authority to CRNAs (and other APRNs). Massachusetts’ subsequent opt-out in 2024 was a logical follow-on to that legislative shift. Legal challenges to these moves (if any) have not succeeded; instead, anesthesiologists have had to double-down on demonstrating their value and pushing hospitals not to abandon the team model even when not legally required.

In summary, the legal and policy battleground has seen mixed outcomes – some wins for physician-led care (court victories in title protection, vetoes of NP/CRNA expansion bills) and some losses (numerous states opting out or granting CRNAs independence). The overall trajectory is worrisome for anesthesiologists who fear a slippery slope where lack of legal requirement for oversight leads to hospital practices that sideline physicians. Yet, the fight is far from over, and anesthesiologist advocates continue to leverage every tool (legislation, regulation, litigation, and public opinion) to emphasize that anesthesia is, and should remain, the practice of medicine.

The Future: Protecting Anesthesiology and Patient Safety for the Next Generation

For physicians entering or considering the field of anesthesiology, the current scope creep trends serve as a wake-up call. On one hand, anesthesiology remains a vital and rewarding medical specialty with high levels of patient trust and excellent outcomes. On the other hand, the push by midlevel providers to assume independent roles presents challenges to the specialty’s identity and perhaps its long-term viability. Is it dangerous to allow midlevels to assume independent control of anesthesia care? From the perspective of physician anesthesiologists and the evidence we’ve reviewed, the answer is yes – it introduces dangers that a new generation of anesthesiologists must be prepared to address.

Patient safety is the paramount concern. Anesthesiology trainees of today should remember that every time they take a patient into their care, they bring an irreplaceable level of expertise to the table. If trends led to fewer anesthesiologists supervising more CRNAs or being absent entirely, those patients lose the safety margin of having a doctor immediately present. Future anesthesiologists will need to be not just clinicians but also advocates for their patients and their role. This could mean speaking up in hospital committees about why certain cases require physician management, or educating administrators on the hidden costs of adverse outcomes that might arise from lower staffing of physicians. It certainly means getting involved in advocacy through organizations like ASA and state societies, to help shape laws and policies. The ASA is actively recruiting early-career physicians to lend their voice, recognizing that the legislative battles in the coming years – over supervision requirements, scope of practice definitions, and reimbursement models – will determine the landscape in which new anesthesiologists practice.

Another aspect of the future is the job market and specialty attractiveness. Some medical students worry that if CRNAs continue to expand, anesthesiology could face a scenario like what’s happened in primary care or emergency medicine in some areas – where the influx of non-physician practitioners leads to fewer jobs or lower compensation for physicians. While anesthesiology is still in demand (and projections actually show a significant anesthesiologist shortage looming in the next decade), it’s true that unchecked scope expansion could undercut the profession. If hospitals perceive that they can “get by” with cheaper providers for many cases, they may hire fewer anesthesiologists, potentially worsening the shortage of anesthesiologists in a self-fulfilling way. Protecting the specialty thus has an economic component as well: anesthesiologists must demonstrate their value-add – in safety, in handling critical cases, in improving perioperative outcomes and efficiencies – such that replacing them with midlevels is clearly seen as an inferior option. Fortunately, many healthcare systems and surgical leaders do recognize the irreplaceable contributions of anesthesiologists, especially when it comes to quality of care and patient satisfaction. It’s no coincidence that surgical mortality rates dropped and anesthesia catastrophes became exceedingly rare in the era of physician-led anesthesia teams. The next generation should continue building on that legacy of safety and not allow standards to be eroded for short-term gains.

Looking ahead, collaboration will also be key. While this article has taken a firm stance that independent midlevel practice in anesthesia is dangerous, it’s not to say that anesthesiologists and CRNAs are enemies. In fact, the care team model works precisely because it leverages the strengths of each – with mutual respect. Many anesthesiologists train and work side by side with excellent CRNAs every day. The ideal future model might involve anesthesiologists leading larger teams that include both CRNAs and AAs, extending the physician’s reach without abandoning oversight. Innovative solutions like the “Anesthesia Care Team 2.0” could emerge, where one anesthesiologist uses technology and well-defined protocols to direct a slightly bigger team but remains intimately involved in critical portions of each case (this concept is being explored to mitigate shortages while keeping care physician-led). Such models can only succeed if regulatory frameworks continue to mandate physician involvement and if anesthesiologists insist on high standards rather than relinquishing control. As Dr. Ronald Harter (ASA past president) said, “Physician-led care is the status quo and the model that safeguards patient safety” – even if a handful of states experiment with other setups, it’s incumbent on the medical community to show why that status quo is worth preserving.

In conclusion, scope creep in anesthesiology by non-physician providers is a complex, evolving issue with high stakes. The current state is one of active contention: legislation and policy are trending toward more autonomy for CRNAs, while anesthesiologists double down on patient safety arguments to counter that trend. Implications of allowing midlevel independent practice include potential declines in care quality, increased risk in complex cases, and a reshaping of the anesthesia workforce that could marginalize physicians. From a physician advocacy perspective, caution is not just warranted – it is essential. The danger of midlevel-only anesthesia care is real, as evidenced by regulatory citations, veteran health studies, and the fundamental knowledge gap between a nurse’s training and a physician’s training. Those entering anesthesiology should not be disheartened, but rather galvanized: the specialty absolutely needs bright, motivated physicians to continue advancing the field and ensuring that every patient undergoing surgery or anesthesia receives the best possible care. By staying informed, engaging in advocacy, and working collaboratively but firmly to define roles, anesthesiologists can safeguard the future of their specialty. The mantra going forward must be “patient safety first” – a principle that underpins the call for physician-led anesthesia. As the ASA and AMA remind us, patients deserve nothing less than a fully qualified physician at the helm of their anesthesia care. The coming years will determine if we as a medical community can uphold that standard in the face of pressure – for the sake of our patients and the integrity of anesthesiology as a medical specialty.