Leadership to Benefit Patients: What I've Learned about the Nurse Anesthesia Profession

Joseph L. Fink III, J.D.
Former Public Member of the Board, NBCRNA

Joseph L. Fink III, J.D.
Public Member, NBCRNA (2008-2015)
(Fall 2015)

of the post-World War II Baby Boom, I grew up in a small town, Tyrone, in the Appalachian portion of Central Pennsylvania. When I was a youngster the population of the town was about 7,000; now it’s around 4,000. There was a hospital in town constructed with Hill-Burton Program funds after World War II. The professionals in town included three physicians who were general practitioners and one surgeon. There was no anesthesiologist but thankfully, there was one CRNA. Her surname (I cannot recall her first name because no one ever used it) was Cimino and everyone called her Cimmy. Cimmy was about 4’ 11’ in height but very much taller when her stature in the community was measured. She was what made needed surgery possible and she was always ready to serve. She was different from the other nurses at the hospital who in those days wore the traditional white nursing uniforms, white stockings and shoes, and one of those distinctive white nursing caps; Cimmy always wore scrubs and a colorful bandana. (In that era in Appalachian Pennsylvania all nurses were female).

I first got linked with the NBCRNA during the 1990’s when Peggy McFadden, a CRNA from the Lexington area where I now live who was enrolled in a graduate health law course I was teaching at the University of Kentucky, approached me about an opening for a Public Member on the Council on Recertification. That was in the days when the Council on Recertification was separate from the Council on Certification. I served in that role as Public Member from 1993-1999. I was succeeded by my best friend (other than my wife), Larry Simonsmeier, J.D., from Portland, OR.

During that period I had the honor of working with Susan Caulk, CRNA, truly a living legend in the nurse anesthesia field. That first stint as Public Member started my learning curve about nurse anesthesia, a process that continues to this day. My service with NBCRNA concluded after the September, 2015 meeting. What have I learned during this opportunity to serve?

First and foremost, NBCRNA’s obligations run to the public and, as a result, on to the individual patient. This is in contrast with a professional membership organizations such as the AANA, the principal purpose of which is to advance the interests of the profession. One of my key responsibilities as the Public Member was to remind everyone of that at key points or junctures in discussions. My experience was, fortunately, that the NBCRNA members did not need reminded of that expectation very often; patient welfare was always at the fore of the considerations of the Board members and staff.

Members of the NBCRNA and the outstanding staff members perpetually have kept their focus exactly where it should be on the health and welfare of patients being served by CRNA’s. During my six year tenure there have been extremely few times when I have felt the need to discharge my responsibilities as the Board member charged with asserting the view of the public to remind everyone of our collective and principal overarching purpose. That reflects all the best on the efforts of the NBCRNA members with whom I have served.

I have been a first-hand witness to the very sound decision making of the members of the NBCRNA. Board members make a very substantial commitment of volunteer time along with motivation and dedication to their service in this role.

As Chair of the NBCRNA Review and Appeal Committee I had the privilege of working with the Committee members, staff and Legal Counsel to assure that a mechanism or pathway was working well for consideration of exceptional circumstances that interfered with pursuit of initial certification or renewal of certificant status. Balancing the central concern for patient welfare with the need for appropriate flexibility and compassion when considering exceptional circumstances has been the focus of that group.

From time to time it has proven helpful to ask myself “What does the patient expect when the CRNA is seated by the side of the operating table?” Here’s what I have concluded:

  • Provider competence;
  • Care consistent with the highest contemporary standards irrespective of location -- urban, suburban or rural;
  • Care consistent with the highest contemporary standards irrespective of age, gender or ethnicity of provider; and
  • Accountability and transparency

All of this came home to roost when I was diagnosed with prostate cancer in October, 2010. I chose the surgical approach to dealing with that challenge and received great benefit from the services of Christie Arkle, CRNA, at the University of Kentucky Hospital. That experience as a patient has been carried forward through my service with NBCRNA. It has colored or flavored my service as a Public Member of the Board.

It has been my experience that professionals sometimes view themselves as being in a field where only others in the specialty can assess their abilities. But beginning with the addition of non- licensee members of the public to professional licensure boards during the consumer movement of the 1970’s, patients and the public have come to recognize and assert their role in assuring the professional competence of those who practice on them.

After all, it was the public, acting through the agencies of government, that granted the initial licensure to practice nursing through the actions of legislatures and nursing licensure boards. Subsequently, membership on those same nursing boards, acting on behalf of the public, was expanded to include a seated public member from outside the profession. About the same time along came mandatory continuing professional education for renewal of licensure. This involvement of a representative of the public perspective was carried forward to the Councils on Certification and Recertification and thus on to the NBCRNA.

And what does the public think? Programs aimed at professionals and collectively designated as “maintenance of competence” are important. A 2010 survey sponsored by the American Board of Medical Specialties and focused on physicians found that 95% of the public rates participation by their physician in maintenance of competency activities as important.

Another study focused on physicians by Consumers’ Checkbook, an independent nonprofit consumer organization founded during the 1970’s, found that “participation in an on-going maintenance of competence program is evidence that a physician is taking extra steps beyond getting initial certification to continue to keep up-to-date and improve.” Fortunately, the vast majority of CRNA’s recognize and acknowledge this responsibility.

And finally, at the risk of being indicted for overly focusing on colleagues in the medical profession, a quotation from an article in the December 10, 2014 issue of JAMA provides insight:

​“Professional societies and physicians have a duty to criticize the problems with Maintenance of Competence programs, but also to participate actively in improving them. They must guard against the temptation to ‘dumb down’ measures to appease angry colleagues, and thus run the risk of ending up with an MOC system that simply does not accomplish the task at hand, a commitment to lifelong learning. They should recognize the difficulty of creating what physicians want a system that evaluates them based on what they do, but does not disrupt then as it does so.”*​

Graduate Medical Education programs in anesthesia will never produce a sufficient number of anesthesiologists to meet the total demand for anesthesia-related services and to facilitate all the surgical procedures necessary to preserve and restore the health of Americans.

During my short time serving both the public and the nurse anesthesia profession, the profession has grown in scope and number of practitioners. Now there is even subspecialty certification for CRNA’s who focus their practices on non-surgical pain management. Think of all the various procedures and interventions available to address maladies now that were unavailable when I was growing up in Central Pennsylvania.

It has been an honor to have worked with a parade of outstanding leaders, starting with Susan Caulk and Karen Plaus and on through many others on the staff in the Illinois office, as well as the volunteers, both CRNA’s and non-CRNA’s, with whom I’ve been privileged to serve over the years. With my two stints of service on the Council on Recertification from 1993-1999 and then on the NBCRNA from 2008-2015 I have learned a tremendous amount. I will be eternally grateful for this tremendous opportunity.


* Lee TH. Certifying the Good Physician: A Work in Progress. JAMA 2014(Dec 10);312:2340-2342.