Counterarguments

No title can be used if the title is not legally authorized

The argument could be advanced that a CRNA should not use the term because no law specifically permits a title other than CRNA. This argument stems from the notion that the legislature, in providing a title for CRNAs to use, declared that no other title or term could be used. The use of CRNA as a protected title is discussed below.

If the law does not expressly limit the title that can be used, it would be a stretch to conclude that the law should be construed to mean that the reserved title is the only title that can be used. Clearly, it might be argued that the legislature intended a CRNA to be permitted to use only the specifically created title. However, if the law addresses who may use the specific title, that reservation should not be given a broader construction that the title limits both who may use the title and limits what title the user must use or may only use.  Indeed, many examples exist throughout the medical professions allowing the use of other descriptors or titles that are recognized by associations, facilities, and individuals such as Advanced Practice Provider, mid-level provider, Advanced Practice Registered Nurse, and Anesthesia Provider. 

 In short, if the law does not declare that a CRNA may use only a specific title, the argument that the law restricts the use of a title only if legally authorized would be incorrect. 

A protected title already exists for CRNAs

A separate but related objection might be raised that CRNAs already have a reserved title, and therefore the CRNA should not also be permitted to use another title or descriptor. This argument rests on the foundation that the legislature’s creation of a title and reservation of the use of this title by only those who had been educated, met qualifications and demonstrated competence, meant to do more than prevent the public from being misled by those who hold themselves out as CRNAs. When the legislature directed that only those who are qualified may apply for and use the designated credential, the legislature had a purpose of preventing the public from being misled by others lacking the education and training, who might use the title to create the impression of a competency and practice scope that had not been conferred by law.

As noted previously, if the law does not restrict the use of any other title, it would be a stretch to reach the conclusion that the law must be understood and applied to prohibit the use of any title other than the reserved title.

Again, the argument could be advanced that with a title created by statute, as a matter of judgment, those given exclusive use of title should use that title, and by failing to use that title, the grant created by the law is being undervalued or squandered. But the application of a law to restrict others from using a title to declare that those who may use that title may only use that title, would be a misreading of the law absent an express declaration in the law to this effect.  Clearly, to make this argument, it would have to be argued that the legislature had intended a CRNA to be permitted to use only the specifically created title.

However, against a backdrop in which the law does not expressly contain this limitation, the better argument would seem to be that the law does not have this meaning or effect. 

In short, if the law does not declare that a CRNA may use only a specific title, the argument that because the law gives CRNAs the exclusive use of a title, it would be incorrect that this is the only title that may be used.

The use of “nurse anesthesiologist” could be misleading

The argument could be made that the use of the term “nurse anesthesiologist” is misleading. However, if this argument is advanced, the argument must be more fully understood and analyzed to determine in what way the title or term is misleading. 

First, does the use of the title convey the impression that the nurse is being passed off as a physician? Given the ASA’s own research, it would follow that the use of the title cannot – and should not – be understood to convey the meaning that the user is a physician because the title makes clear that the user is a nurse.

Second, does the use of the title convey the impression that the nurse is being passed off as a person able to provide services that include anesthesiology when the law does not permit these services to be provided by that person? Assuming the scope of practice that the person is legally permitted to perform includes the performance of services that include anesthesiology by law then it would follow that the use of the title cannot – and should not – be understood to convey a misleading meaning. Assuming CRNAs are allowed by law to provide services that include anesthesiology, then it follows that the use of the title is not misleading on this ground.

Anesthesiologist is already defined as a physician in certain states

“Anesthesiologist” has a statutory definition in 3 states.  While legal opinions will undoubtedly vary whether “nurse anesthesiologist” and “anesthesiologist” are legally distinct terms, it remains that adding the title “nurse” must influence the meaning of the word that follows even in the most conservative interpretation.  It is notable that other states (18) have regulatory definitions of “anesthesiologist”.  However, these laws must be interpreted in light of the fact that the ASA now refers to its members as “physician anesthesiologists” (see end packet insert).  None the less, members should use detailed consideration and judgement as to the specifics of the law in their state.

Additionally, precedent demonstrates that the AANA advocates on behalf of its members on most issues using a state-by-state approach (i.e., pain management) and the term remains completely optional for members to use based upon state law and prudent discretion.

The use Nurse Anesthesiologist could trigger lawsuits

No law prohibits the use of this identifier. The possibility that others might mount a campaign – or a lawsuit – to challenge the use of the title is just that – a possibility. But this possibility does not mean such an effort is correct or will succeed. Instead, the question to be resolved should focus on whether the legal (including policy) arguments that might be advanced would gain acceptance. And the resolution of this question would necessitate an analysis of the basis of the legal arguments.

As outlined above, with the assumption that the law does not bar the use of “nurse anesthesiologist,” and having discussed whether the law can be construed not to limit the title that CRNAs may use and that the use of the term is not misleading, another question might be whether the use of the title is somehow reserved as a matter of intellectual property law. Although beyond the scope of this discussion, recent efforts to achieve intellectual property protection for the title “nurse anesthesiologist” have failed because the title is viewed as too generic. If this is true for nurses, the conclusion would seem to be equally true for medical doctors.

Nurse Anesthesiologist is not protected

One additional argument against the use of the title or term “nurse anesthesiologist” could be that it is not protected. In other words, because the title is not protected, it may not be used.

A variation of this argument has already been explored in an earlier discussion about whether the law restricts the title that CRNAs may use. As with that argument, the conclusion that absence of title protection infers that the title cannot be used would seem to be an overstatement. Otherwise, a similar argument might be made that no one may use the title “anesthesiologist” because no protection exists for the use of this title by any person and no law restricts the use of this title by members of a given profession. But it would be absurd to make the argument that because no title protection exists in the medical field, the law bars a physician who practices and is qualified and trained to provide anesthesiology services from being held out to the public as an anesthesiologist. This same conclusion should be sufficient to address this final objection.

In every jurisdiction in which CRNAs practice, the scope of physicians and CRNAs involves the delivery of anesthesia, i.e., the practice of anesthesiology.   As such rather than trying to endlessly compare or fight, participants in this dialogue should be motivated to recognize that both CRNAs and physicians, as experts in the field, work together to maximize benefit for patients and society.  Despite the ASA’s insistence that nurse anesthetists are equivalent with their assistants, “Nurse Anesthesiologist” is not meant as a provocation, but instead as a point of clarity that multiple professionals are experts in the field of anesthesia.   If the ASA has issue with the undeniable fact that nurse anesthetists are, in fact, experts – then we can only suggest they realize that  working together we can generate more benefit for patients than by trying to minimize one another.