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SB1336 lowers standard of care for all patients


As a practicing orthopedic surgeon in Show Low, Arizona, I have dedicated my life’s work to improving both the quality of and access to care in rural Arizona. SB 1336 will not improve rural access or care anywhere in Arizona.

First, SB 1336 creates a patient safety issue. If the bill goes forward in its current form, the standard of physician direction of patient care, which provides a necessary safety net for the patient in the operating room, would be removed. This is dangerous for Arizona patients. It has nothing to do with increasing access to care as proponents of the legislation claim.


Ronnie Dowling

Altering the definition of direction will not mean there are suddenly more Certified Nurse Anesthetists (CRNAs) living and practicing in rural areas. CRNAs are utilized to provide anesthesia for patients who are undergoing procedures performed by a physician; thus there is always a physician when a patient is administered anesthesia, for it is the physician who performs the procedure. If there is no physician, there is no procedure and no need for a CRNA. Saying this bill would increase access to care is simply not true.

The system currently in place works well just as it is.  I provide care for my patients in the operating room, frequently in conjunction with a CRNA’s services. My patients expect that I, as the surgeon with whom they have built a relationship and trust, will be in charge. A surgical patient generally only meets the CRNA once, on the day of his or her procedure.

SB 1336 erodes safe patient care.  When a crisis occurs – and while infrequent, unfortunately sometimes do – it is critical to recognize the cause of the problem and take corrective action. It is the physician who has been trained to take charge and handle the situation causing the emergency. Physician direction is a must for our patients. This bill will create a problem with regard to who is really in charge, the doctor or the CRNA. A seemingly small change in statutory language can make all the difference to a patient who no longer has a physician personally responsible for his or her overall care.

To prepare for the decision-making required to medically address life and death emergencies, physicians like myself undergo years of intense, formal, post-college medical education and residency training. Medical school and residency establish standards of clinical training that is commensurate with the responsibility of making irreversible life and death decisions.  After medical school, I had five years of a surgical residency with call every other night, followed by a trauma fellowship participating and training in thousands of surgical cases prior to entering private practice.
While advance practice nurses like the CRNAs are an essential part of the care team, their education is not designed to prepare them for the many aspects of evaluating, diagnosing and treating a patient that can be required, especially in an emergency situation.

The best surgical outcomes demand a highly qualified, intensely trained, experienced individual responsible for the patient during surgery.  Patients deserve to undergo a procedure with a designated leader trained to supervise the team. To achieve optimal surgery outcomes, the team must be coordinated and led by a professional with the education, training and skillset to act at the highest level and that is a physician.

SB 1336 is a step backwards in patient care.  Rural and urban Arizonans alike deserve health care delivered by those who have been extensively trained in the broader practice of medicine. Rural citizens like my neighbors in Show Low will not accept marginalized care.

SB 1336 would erode my ability to direct the management of my patients’ care. It fragments the effectiveness of the health care team. It doesn’t make things better – it makes things worse.  It is dangerous for our patients.

Ronnie Dowling, M.D. is an orthopedic surgeon at White Mountain Surgical Specialists in Show Low.



The views expressed in guest commentaries are those of the author and are not the views of the Arizona Capitol Times.


  1. She does one case every few months. And is not even Board certified. She is in the pocket of ArMA wanting a medical association position in the national level. This is the same bs over the over again without any evidence what so ever. The patient only meets the MDA once as well so are you directing the MDA’s anesthesia as well? Because you have built such a strong and trusting relationship with your patient? I can assure you most surgeons, including this one, would have not be of any help if there was an anesthesia emergency. SB 1336 improves access to patient care by decreasing surgeons perceived increase in liability. There are ducmented cases of where surgeons have not come to practice at a rural hospital due to fear of increased liability. In your case, you are suggesting that you as the physician know everything about everything and those day are long gone. Let surgeons operate. CRNA’s don’t tell you how to do a case. CRNAS are highly tried anesthesia professionals. Numerous studies have found the same conclusion. We are just as safe. This is so coming that it is beginning to lose all teeth. When you have no eveidnece the only resort is fear. Trust me. When you lead the team it is not better for anyone. I can assure you if an emergency happens. She has no idea how to handle it.

  2. As a CRNA who has worked with Dr Dowling in Show Low and Springerville I found this opinion piece interesting, but not factual and without evidence.

    Dr Dowling is incorrect when she states the term “direction” does not impact access of care. Surgeons who I work with daily (99% of which wrote letters in FAVOR of this bill) as an independent CRNA in Show Low have expressed this VERY concern that they could be liable for my actions. Several rural hospital CEOs AND our own facility has either had difficulty or were UNABLE to recruit some surgeons because of this concern. Not only have over 70 surgeons written letters to this effect but also several hospital CEOs have expressed their support of this bill. Redefining direction indicating that the surgeon does NOT have liability as SB1336 does, resolves these concerns. A perfect example is the video below where a rural hospital CEO explains exactly that. See Reference below #8,9 as well.


    Dr Dowling mentions that anesthesia does not happen without a surgeon. However, the corollary is also true, surgery generally does not happen without anesthesia. Ergo, one does not exist without the other, it is not one sided. Therefore, when there are obstacles to surgeons working with CRNAs there is, by definition, an obstacle to access to care. The reality is that YES, defining the term ‘direction’ so that it infers NO liability upon the operating practitioner DOES positively impact access to care by removing a barrier to surgeon recruitment and Frankly, this is not debatable.

    Dr Dowling seems to suggest that if an emergency occurs in the operating room which isn’t surgical, that the surgeon would take over and run the show. First let me state clearly that in a decade of working independently as a CRNA I have never experienced this. The reality is that when something untoward occurs (other than a surgical issue) the surgeon expects me to take care of it while they take care of the surgery. We work as a team in our respective disciplines to get our patient safely through any emergency but our roles are quite distinct. I manage the anesthesia including the vital signs and any medications which will be administered and the surgeon manages the surgery. It would be as inconceivable to expect a surgeon to understand and manage the medications I use multiple times a day as it would to expect me to offer advice on how to perform the surgery. In fact, physician representatives of the Arizona Medical Association agreed with this and below are the videos of them stating it in their own words.



    Dr Dowling suggests that SB1336 may cause confusion as to who is in “charge”, but this misrepresents the relationship which already exists. There is not someone in ‘charge’ there is an expert in surgery and an expert in anesthesia working together as a team in the best interest of the patient. Since it not debatable who is the expert in anesthesia why should a surgeon be at risk for liability for something they have no expertise in? It just makes no sense and the perception or concern of liability can only serve to DISTRACT the surgeon from doing what they do best, surgery.

    Dr Dowling makes the statement that citizen in Show Low would not accept ‘marginalized’ care. These are my neighbors as well and I can assure everyone that my care is not ‘marginalized’ by any means. I have put our own surgeons, their wives and their children, friends, family, prominent community members and most recently the father of United States Senator Jeff Flake to sleep. If there were any concern with my expertise in anesthesia I can assure you that everyone in this small town would know. So no, this bill does not represent a step backward in patient care, it represents the reality of practice today simply removes the concern of liability from the surgeons shoulders.

    Lastly, the suggestion that it could be ‘dangerous’ to our patients is both disingenuous fear mongering and contrary to evidence over the last one hundred and fifty years that CRNAs have been practicing anesthesia independently. It is indisputable that every study done on the topic shows CRNAs provide the same safe, high quality care as our physician anesthesiologist colleagues. The evidence is clear. There are no safety concerns, no increased risk and certainly no ‘danger’ created by this SB1336. Evidence below #1-7.
    SB1336 is not only good for surgeons it is good for Arizonans. It simply defines the term direction to codify the roles of both the surgeon an CRNA on the team so that the surgeon can focus on what they are the very best at, surgery.

    1. Negrusa, B., Hogan, P. F., Warner, J. T., Schroeder, C. H., & Pang, B. (2016). Scope of Practice Laws and Anesthesia Complications. Medical care, 54(10), 913-920.
    2. Beissel, D. E. (2016). Complication rates for fluoroscopic guided interlaminar lumbar epidural steroid injections performed by certified registered nurse anesthetists in diverse practice settings. Journal for Healthcare Quality, 38(6), 344-352.
    3. Dulisse, B., & Cromwell, J. (2010). No harm found when nurse anesthetists work without supervision by physicians. Health Affairs, 29(8), 1469-1475.
    4. Simonson, D. C., Ahern, M. M., & Hendryx, M. S. (2007). Anesthesia staffing and anesthetic complications during cesarean delivery: a retrospective analysis. Nursing research, 56(1), 9-17.
    5. Needleman, J., & Minnick, A. F. (2009). Anesthesia provider model, hospital resources, and maternal outcomes. Health services research, 44(2p1), 464-482.
    6. Pine, M., Holt, K. D., & Lou, Y. B. (2003). Surgical mortality and type of anesthesia provider. AANA journal, 71(2), 109-116.
    7. Lewis, S. R., Nicholson, A., Smith, A. F., & Alderson, P. (2014). Physician anaesthetists versus non‐ physician providers of anaesthesia for surgical patients. The Cochrane Library.
    8. Jordan, L. (2011). GUEST EDITORIAL. Studies Support Removing CRNA Supervisioin Rule to Maximize Anesthesia Workforce and Ensure Patient Access to Care. AANA journal, 79(2).
    9. Liao, C. J., Quraishi, J. A., & Jordan, L. M. (2015). Geographical imbalance of anesthesia providers and its impact on the uninsured and vulnerable populations. Nursing Economics, 33(5), 263

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