Hello Everybody:

I got this e-mail from the president of the Missouri Society of Anesthesiologists, please read it, and follow the embedded link.

To those of you who are not able to read the entire message, here is a synopsis:

1. CMS (medicare) currently only reimburses physicians supervising residents 50% of what we bill for (i.e., medicare essentially gets 2 cases for the price of 1).

2. The ASA had been working for the past 3 years to correct this.

3. The AANA (amer. asscn nurse anesthestists) has lobbied against this, because they would like this disincentive for training residents to continue.

Anyway...here is the letter....if you have a few minutes, please send follow the link and write a letter to CMS.
*************

Urgent Email Communication from the MSA President
Dear MSA member:
The medical specialty of Anesthesiology is under attack and we need your help!
We have received an urgent communication from ASA leadership regarding their work over the past 3 years to correct the current inequity in reimbursement for teaching anesthesiology residents.
Use this link www.asahq.org/news/cmsproposal082405.htm to go to the ASA home page Action Alert on the anesthesiology teaching payment rule. The Action Alert will provide you a direct link to the easy to use CMS e-comment page and to our CAP WIZ page. A sample letter and bullet points are available on these sites to help you craft your message.
Currently teaching anesthesiologists are penalized by Medicare for supervising anesthesiology residents. The ASA has worked hard to correct this and had been on the verge on correcting this by Federal Rule.
The ASA learned just last month that the AANA has been working diligently through their political action committee to stop the correction in reimbursement for teaching anesthesiology residents sought by the ASA. The AANA recognizes that the current underpayment works as a disincentive to train anesthesiology residents. They do not want it corrected and have spent a great deal of energy to stop it.
The AANA lobby effort against anesthesiology teaching programs is full of the same rhetoric that was thrown around Washington a few years ago during the Medicare CRNA independent practice debate. The AANA believes strongly that there is no difference in anesthesiologists and CRNAs, except that it cost a lot more to educate anesthesiologists.
The ASA leadership is furious that the AANA worked behind their back to fight the ASA led effort to help anesthesiology teaching programs, despite the AANA promise to not oppose this effort.
There have been significant efforts to reach out to the AANA in Washington and the chapter here in Missouri. We have learned a great lesson. In the mean time we my work to counter the surprise attack against this important rule change. Please clink on the link below to help in our effort to save academic anesthesiology and residency training programs:
www.asahq.org/news/cmsproposal082405.htm
Sincerely,
John Menius, MD
MSA President

OMG. Time to start playing catch-up b/c while we were sleeping the aana was slippin' it to us.

Can medical students get in on the action? This really underscores the fact that the ASA needs to constantly be on the move as opposed to reacting to jabs from the aana.

OMG. Time to start playing catch-up b/c while we were sleeping the aana was slippin' it to us.

Can medical students get in on the action? This really underscores the fact that the ASA needs to constantly be on the move as opposed to reacting to jabs from the aana.

Anyone can submit comments regarding this issue.

And do you really think the ASA has not been aware of this issue? It has been very well publicized within the ASA.

Posted about twice previously, but still a good topic to keep up:

http://forums.studentdoctor.net/showthread.php?t=223491
http://forums.studentdoctor.net/showthread.php?t=224682

Why is the aana against this? What do they have to gain from it?

Why is the aana against this? What do they have to gain from it?

Getting reimbursed for two cases with residents instead of just one makes residents more financially viable in cash strapped hospitals. In other words, POTENTIALLY less jobs for CRNA's.

No surprise there at all. I sent my letter three weeks ago. We need other students to do the same. Hire AAs instead of CRNAs to teach the beotches a lesson.

That's the exact action that should be done here. You guys need to get serious about promoting AA's (not over CRNA's, but simply promoting AA's)

But AA's won't be able to help if they aren't able to attain licensure at that particular state. So, perhaps a joining of forces is in order? I'm just a lowly pre-med, so what do I know. But, I am stayin in a HolidayInn Express tonight!! (have an AZCOM interview in the a.m)

Good luck with this issue. I'd like to follow it as it evolves.

That's the exact action that should be done here. You guys need to get serious about promoting AA's (not over CRNA's, but simply promoting AA's)

But AA's won't be able to help if they aren't able to attain licensure at that particular state. So, perhaps a joining of forces is in order? I'm just a lowly pre-med, so what do I know. But, I am stayin in a HolidayInn Express tonight!! (have an AZCOM interview in the a.m)

Good luck with this issue. I'd like to follow it as it evolves.
Why thank you! We AA's will take all the promotion we can get. ;)

CMS (medicare) currently only reimburses physicians supervising residents 50% of what we bill for (i.e., medicare essentially gets 2 cases for the price of 1).


Has this always been the standard?

CMS (medicare) currently only reimburses physicians supervising residents 50% of what we bill for (i.e., medicare essentially gets 2 cases for the price of 1).



The inequity here is that surgery residents can be covered 1:4 with their attendings, while anesthesia residents can only be covered 1:2. Anesthesiology simply wants to be covered and compensated in the same equitable manner.

The inequity here is that surgery residents can be covered 1:4 with their attendings, while anesthesia residents can only be covered 1:2. Anesthesiology simply wants to be covered and compensated in the same equitable manner.

Actually, surgeons can get reimbursed for 2 rooms as long as the "key/critical" portions of the cases do not overlap (i.e. surgeon and resident work in room 1 while resident starts or finishes cases in room 2).

HOWEVER, the anesthesiologist supervising the anesthesia residents in those two rooms will only be reimbursed at 50%.

The 1:4 ratio refers to internal medicine and other such specialties who can oversee 4 residents performing clinic duties (but not for procedures).

This effort by the AANA, to me, reveals that they have absolutely no interest in cordial relations with the ASA. To actively lobby AGAINST a proposal that really has ABSOLUTELY no relevance to their profession at all other than perceived competition down the line sickens me. This isn't about "autonomy" or "outcomes"--it is simply an attempt to maintain a regulation that hamstrings the ability of academic programs to function.

Previously before hearing about this lobbying effort I had mostly positive things to say about CRNA's. At my program we have always had an excellent working environment with them. However, I now realize that the AANA has no interest in any sort of relationship with anesthesiologists in general--to them, we are all the enemy and, apparently, they will do anything to hurt our profession.

Actually, surgeons can get reimbursed for 2 rooms as long as the "key/critical" portions of the cases do not overlap (i.e. surgeon and resident work in room 1 while resident starts or finishes cases in room 2).

HOWEVER, the anesthesiologist supervising the anesthesia residents in those two rooms will only be reimbursed at 50%.

The 1:4 ratio refers to internal medicine and other such specialties who can oversee 4 residents performing clinic duties (but not for procedures).


My bad. But the surgeons get full fee, right? They're getting two full fees for essentially concurrent surgery while anesthesiology only collects 50% on each.

My bad. But the surgeons get full fee, right? They're getting two full fees for essentially concurrent surgery while anesthesiology only collects 50% on each.

Yep...even if those two surgical cases only overlap by 1 minute the anesthesiologist will only get reimbursed 50%.

This person is a CRNA. Go away you evil doer.

No, I'm not a CRNA, student. And no.

Haha! You edited your post, silly.

You are making assumptions and personally attacking me with no merit. Last week I wrote to ASA Secretary Bob Wallace to ask if I could join. Primarily, I like to read the journals, but I like to learn about both sides (and was willing to pay money to ASA). I was interested in an educational membership. I'm not your competition. Haven't even been admitted yet. Why not play fair and read the rest of my profile to the others. Especially the part where it says "interested in candid dialogue about anesthesia."

Whatever professional organizations dictate to us does not mean that we must assent. Case in point.

And sorry about being sarcastic earlier. I want to be accepted by this forum without covertly choosing a screename, or ceasing to point out who I really am.

Alright now folks, let's play nice or Venty will be forced to close the thread.

In the words of Vent, "TL, you are forcing me to read your peevish babble after having placed you on my ignore list. This is something I'd rather avoid doing if possible as it is quite exasperating.

For the curious and interested, the ignore function can be found in "User CP" (at the top o' your screen) under the 'Miscellaneous' tab. Use it."

I will. :laugh:

I will accept your apology if you promise to call 1-800-FUK-CRNA and leave a message stating how much CRNAs suck. :laugh:

Alright Tough, ya gotta back off, bro. Yours was an unprovoked attack. I reread dude/dudettes post and there was no means for attack.

Back down, Lieutenant.

Alright Tough, ya gotta back off, bro. Yours was an unprovoked attack. I reread dude/dudettes post and there was no means for attack.

Back down, Lieutenant.


If I may officially echo JetProp's post - you're outta line my friend. Like it or not, EtherRN has just as much right to be here & participate as you do. The medical professional world would do so much better if we minimized all the internal squabble. Believe me, out here in the real world we have much larger threats to worry about than CRNA vs MD/DO anesth...or MD vs DO for that matter.

Long & short of it - play nicely! :meanie: If you cannot be nice, just don't interact with EtherRN. These are basic people skills that we will all need to master to be successful professionals...and if you can't, Vent or I will have to stick you in time out. :eek:

Thanks to everyone for their patience & understanding by not allowing this thread to turn into a mud-slinging festival!

If I may officially echo JetProp's post - you're outta line my friend. Like it or not, EtherRN has just as much right to be here & participate as you do. The medical professional world would do so much better if we minimized all the internal squabble. Believe me, out here in the real world we have much larger threats to worry about than CRNA vs MD/DO anesth...or MD vs DO for that matter.

Long & short of it - play nicely! :meanie: If you cannot be nice, just don't interact with EtherRN. These are basic people skills that we will all need to master to be successful professionals...and if you can't, Vent or I will have to stick you in time out. :eek:

Thanks to everyone for their patience & understanding by not allowing this thread to turn into a mud-slinging festival!

I feel compelled to respond, Old.
This is a pretty self-regulating board with very few problems. Periodically, however, antagonism does arise in the form of some of us (me included) feeling like we have to defend our turf....with turf meaning the SDN, where people in the anesthesia world come to interact. Occasionally a poster will pop up with obvious ulterior motives, and in that scenerio, I'm locked-and-loaded. I'm not gonna put an ulterior-motive-poster on ignore. They're gonna hear from me.

That being said, yeah, Toughlife jumped the gun on this one, but as you can see he ceased-fire when asked. So IMHO your "official reprimand" was unnecessary.

Had this been a true "threat", however, I would've commenced support-fire. So I don't think its possible to play "nice" all the time. I agree this wasnt one of those times.

If I may officially echo JetProp's post - you're outta line my friend. Like it or not, EtherRN has just as much right to be here & participate as you do. The medical professional world would do so much better if we minimized all the internal squabble. Believe me, out here in the real world we have much larger threats to worry about than CRNA vs MD/DO anesth...or MD vs DO for that matter....



Just to reinforce that this thread is regarding a very large threat that ALL anesthesiologists need to worry about. Just because physicians and CRNA's at your place of business (like mine) may have a good relationship the AANA (which by and large most CRNA's support either directly or indirectly through membership fees) has decided to actively attack the ASA regarding funding for training--an issue that has no DIRECT impact on them.

It is in all our best interests realize this and support "our" political arm.

The deadline for comments to CMS regarding this policy is tomorrow (Sept. 30th). Please everyone do your part to support & protect our profession.

Just to reinforce that this thread is regarding a very large threat that ALL anesthesiologists need to worry about. Just because physicians and CRNA's at your place of business (like mine) may have a good relationship the AANA (which by and large most CRNA's support either directly or indirectly through membership fees) has decided to actively attack the ASA regarding funding for training--an issue that has no DIRECT impact on them.

It is in all our best interests realize this and support "our" political arm.

The deadline for comments to CMS regarding this policy is tomorrow (Sept. 30th). Please everyone do your part to support & protect our profession.


Yes, this is an issue. But at least in the private world, there is a way around the constant worry of the one-anesthesiologist-to-4-crna-reimbursement-rule.

The powers-at-be wanna play hardball? Thats OK. We're just as smart as they are. :meanie:

Is it just this states particular association or the entire AANA. Though portions of AANA membership funding go to state associations the state association has their own leadership and is not controlled by the aana at all. What is on one states agenda may not be on anothers and may or may not be supported by the aana as a whole. The state associations are there to specifically handle local state issues. Sometimes their agenda is backed and futher funded by the aana and sometimes not. This is the first I hear of this and I believe it may be going a little to far. Its not like every hospital in the country can open an anesthesia residency just to not pay CRNA's, so I think it would effect us little in rural areas where we predominently practice anyway.

Though the AANA and ASA always have issues, dont think it is the agenda of the entire AANA to lobby against this bill.

Is it just this states particular association or the entire AANA. Though portions of AANA membership funding go to state associations the state association has their own leadership and is not controlled by the aana at all. What is on one states agenda may not be on anothers and may or may not be supported by the aana as a whole. The state associations are there to specifically handle local state issues. Sometimes their agenda is backed and futher funded by the aana and sometimes not. This is the first I hear of this and I believe it may be going a little to far. Its not like every hospital in the country can open an anesthesia residency just to not pay CRNA's, so I think it would effect us little in rural areas where we predominently practice anyway.

Though the AANA and ASA always have issues, dont think it is the agenda of the entire AANA to lobby against this bill.

Unfortunately, it is the entire AANA and that has driven a major spike into the relationship between the ASA and AANA. There is simply no reason for the AANA to lobby against this issue and it just goes toward souring relationships between the two organizations and its memberships.

dont tell my heart, my achy breaky hrt

I myself do not support this particular state organizations direction, though I have not heard their side, nor the complete ASA side. ALL I know is what has been posted on this board.


Me too. I searched AANA and couldn't find anything.

This isn't something that the AANA wants to proudly and vociferously espouse publicly. They know that this is a divisive issue that can only be construed as anti-physician when at the same time they are trying to put on a show of good will toward the ASA.

The unfortunate part of all of this is that in direct contrast to what they think will happen (less jobs/training opportunities for CRNA's/SRNA's), more income to cash strapped departments would actually allow the departments to bring in MORE CRNA's to help with ridiculous work loads. SRNA presence in these departments would not be reduced because they are already factored into the work load and aren't paid to begin with.

For example, if Parkland's anesthesia department could double the amount of money it takes in on supervised cases with residents, they would use that money to expand the total number of CRNA hours to help with coverage issues, weekend coverage issues, and most of all resident relief to attend educational conferences. More equipment could be brought in which would be used by both physician and nurse anesthesthetists. Pay for both physicians and CRNA's would both likely increase with that influx as well.

To argue that more income would mean less educational opportunities for SRNA's just doesn't hold water.

For the nurse anesthetists here, you should e-mail the AANA and ask them why they are trying to scuttle the legislation and what purpose do they think it will accomplish.

The AANA is not opposed to changing the repayment rules.

THe AANA is opposed to changing the repayment of residents to 100% for two simultaneous cases while leaving the reimbursement for SRNAs at the current 50% for the same two cases.

This in turn would potentially disincline clinical sites to accept SRNA students, when they could make double the money with Anesthesiology residents. Therefore potentially negatively impacting Nurse anesthesia schools and the training of nurse anesthetists.

The AANA agrees with the need for a change in reimbursement schedules but wants the reimbursement for SRNAs and Residents to be the SAME. Where attending anesthesiologists get reimbursed 100% whether an SRNA or resident is doing the case!

Why is the ASA trying to push the changes through without changes to the SRNA reimbursement schedule? Why not make the changes together alongside with the AANA?

I am not trying to bash the ASA, but WHY the push for a U N I L A T E R A L change?

Afterall, Changing BOTH Schedules is good for attending anesthesiologists and hospitals alike!

Thanks for reading

Is the ASA opposed to allowing 100% reimbursement for SRNA-run cases? If so, then I would understand the AANA's interest in opposing full reimbursement in resident-run cases. Or is the AANA expecting the ASA to do all the leg work and get a free ride?

By working for a unilateral change, apparently the ASA is opposed to 100% reimbursement for SRNA cases. WHy? You tell me. The AANAs position has been to work together and change the rules for both party's.

"Is the AANA lobbying to have this rule changed or is it just deliberately opposing any measures supported by the ASA?"

The AANA is for the rule change, so long as it is not unilateral.

The AANA stated their position in writing to the ASA during the "Thought bridge" meetings last spring regarding this issue. Their position was essentially, we will not support a unilateral change, but lets work together to change the reimbursements for both types of anesthesia students which is in the interest of both party's.

The AANAs position on the statemaent has not changed, the ASA is pushing their own agenda and refusing to work together. Why refuse to work together?

"It is not the ASA's job to do the AANA's job. I could understand the AANA's position if the ASA was deliberately boycotting any attempts for full reimbursement on SRNA-run cases but is it?"

Again, You tell me... The appearance is that the ASA does oppose equal reimbursement by refusing to work together. If the agenda is the same, why not unite both forces and work together?

The AANAs position has been lets do it together in both our interests. Instead of working together the ASA is insisting on doing it their way, in their own interest. Being that the AANAs members are the ones potentially hurt by a unilateral change it should be obvious as to why they oppose the legislation.

"Because the ASA is an organization that supports residents and physician anesthesiologists not nurses. Is that a surprise?

Same for the AANA with regards to CRNAs and SRNAs. The point being, the change is in the interestof both party's. Why not work together? ...unless there is some other agenda...

By working for a unilateral change, apparently the ASA is opposed to 100% reimbursement for SRNA cases. WHy? You tell me. The AANAs position has been to work together and change the rules for both party's.

"Is the AANA lobbying to have this rule changed or is it just deliberately opposing any measures supported by the ASA?"

The AANA is for the rule change, so long as it is not unilateral.

The AANA stated their position in writing to the ASA during the "Thought bridge" meetings last spring regarding this issue. Their position was essentially, we will not support a unilateral change, but lets work together to change the reimbursements for both types of anesthesia students which is in the interest of both party's.

The AANAs position on the statemaent has not changed, the ASA is pushing their own agenda and refusing to work together. Why refuse to work together?

"It is not the ASA's job to do the AANA's job. I could understand the AANA's position if the ASA was deliberately boycotting any attempts for full reimbursement on SRNA-run cases but is it?"

Again, You tell me... The appearance is that the ASA does oppose equal reimbursement by refusing to work together. If the agenda is the same, why not unite both forces and work together?

The AANAs position has been lets do it together in both our interests. Instead of working together the ASA is insisting on doing it their way, in their own interest. Being that the AANAs members are the ones potentially hurt by a unilateral change it should be obvious as to why they oppose the legislation.

"Because the ASA is an organization that supports residents and physician anesthesiologists not nurses. Is that a surprise?

Same for the AANA with regards to CRNAs and SRNAs. The point being, the change is in the interestof both party's. Why not work together? ...unless there is some other agenda...

Well said by toughlife on this one.

And as previously mentioned - anesthesia residencies are looking for some parity with reimbursements with other specialty residencies. It's not an issue that even involves CRNA reimbursement - that was never the intent.

Many people, myself included, think the ThoughtBridge process is pretty much a joke. Way too touchy-feely, let's all just get along kind of crap. And just because the AANA mentions their own reimbursement issues during this process doesn't mean the ASA is going to jump on board. Of course you then make the assumption that the ASA isn't cooperating with the AANA.

By working for a unilateral change, apparently the ASA is opposed to 100% reimbursement for SRNA cases. WHy? You tell me. The AANAs position has been to work together and change the rules for both party's.

"Is the AANA lobbying to have this rule changed or is it just deliberately opposing any measures supported by the ASA?"

The AANA is for the rule change, so long as it is not unilateral.

The AANA stated their position in writing to the ASA during the "Thought bridge" meetings last spring regarding this issue. Their position was essentially, we will not support a unilateral change, but lets work together to change the reimbursements for both types of anesthesia students which is in the interest of both party's.

The AANAs position on the statemaent has not changed, the ASA is pushing their own agenda and refusing to work together. Why refuse to work together?

"It is not the ASA's job to do the AANA's job. I could understand the AANA's position if the ASA was deliberately boycotting any attempts for full reimbursement on SRNA-run cases but is it?"

Again, You tell me... The appearance is that the ASA does oppose equal reimbursement by refusing to work together. If the agenda is the same, why not unite both forces and work together?

The AANAs position has been lets do it together in both our interests. Instead of working together the ASA is insisting on doing it their way, in their own interest. Being that the AANAs members are the ones potentially hurt by a unilateral change it should be obvious as to why they oppose the legislation.

"Because the ASA is an organization that supports residents and physician anesthesiologists not nurses. Is that a surprise?

Same for the AANA with regards to CRNAs and SRNAs. The point being, the change is in the interestof both party's. Why not work together? ...unless there is some other agenda...

CMS specifically narrowed the reimbursement issue to resident physicians because it did not consider midlevel provider education in ANY field in this policy review. There was no support for doubling SRNA reimbursement because there was NO PROVISION IN THE ORIGINAL CMS GUIDELINES OR THE RESPONSE as this was a CMS determined physician issue and applies solely to physicians in this legislation.

Once again, let me review the shortsightedness of the AANA:

A doubling of physician resident reimbursement does not suddenly make it unattractive to train SRNA's. Each program has ACGME limits to the number of resident physicians it can train based on its ability to provide time for educational efforts, ability to limit total training time each week, and adequate case numbers, in particular subspecialty case numbers. A program has to apply to expand its class sizes but only gets reviewed for expansion/contraction every 2-4 years and only by 1-5 residents per class, NOT 100%. There are currently NO LIMITS on the number of SRNA's that a program can enroll to train and help with work issues.

Programs that have a significant number of SRNA's cannot suddenly replace all of that man (and woman) power with a resident pool that isn't as readily available as the AANA thinks, and if it were to try, it is likely that the CRNA's there would walk out in protest, leaving an academic program with even more shortages to deal with. Academics want to be academics and not have to run their own cases all day and all night and both physicians and nurses work to help the hospital, each other, and the academic physicians whose work allows our field to continue to evolve and refine itself.

IF the AANA wanted to espouse the SRNA reimbursement issue in earnest, it could have joined forces with the ASA, jointly espoused the need for fair reimbursement of physician resident training cases, hoped for a revision to the CMS policy for physicians, then pushed for SRNA reimbursement equality with the ASA side by side with the precedent already set in CMS policy for physician residents. A win-win situation for academic programs and the AANA, especially for programs that cannot meet ACGME training standards, but still train SRNA's as well as programs with dual training programs.

This was what the ASA had thought was agreed to since CMS would only review the physician training aspect of each specialty's reimbursement schedule. The AANA wanted to expand the issue to include SRNA's, but that additional package would have made it LESS appealing to CMS to alter the policy just by looking at how much more it would cost Medicare/Medicaid. What the ASA did not expect was a behind the doors attempt to subvert their efforts. In the worst, WORST case scenario for the AANA, the ASA would achieve its goal of doubling resident reimbursement, CMS refuses to reconsider SRNA reimbursement schedules, and the AANA could then go to court to argue that since SRNA's participate to the same degree in cases on rotations with physician residents, they are being unfairly discriminated against by CMS. This would force CMS to revise the SRNA reimbursement policy, with a precedent already set, and not knock physician resident reimbursement down to 50%, because the threat would then exist that the ASA would likewise file suit for discriminatory practice for its physicians in training compared to other specialties.

Why do we not just go to court now? We are trying to stay in good standing with CMS and not develop an acrimonious relationship that would lean CMS away from other anesthesiology related issues. Other specialties have a low threshhold for litigation and it has made CMS less pliable to their issues.

This isn't rocket science. This was discussed over and over by ASA and AANA reps and if the AANA decided to travel their own route to support its trainees and not support the ASA's residents, there was no need to try to sabotage the ASA's efforts. The general feeling I get from academic program reps is that enough is enough. They feel that they have worked hard to make the atmosphere as unified as possible, all the while the AANA, while rightfully pushing for its membership's goals, continues to try to reduce physician training and reimbursement issues.

Instead of accomplishing its goal of making CRNA/SRNA presence more attractive, the AANA has done exactly the opposite. Class sizes are being reevaluated by every program this fall and growth in trainee numbers will be looked at on the resident side in detail. The AANA has also provided an impetus for the utilization of AA's as a more viable alternative and this would have been/will be discussed at the ASA in Atlanta. Some programs are now providing locums contracts to private practice anesthesiologists with creative financing and insurance coverage that allows the hospital to pay the anesthesiologist a minimum stipend while still making it attractive for the physician to cover cases at these academic programs and now cheaper (to the hospital) than paying a CRNA. More alternatives to CRNA/SRNA involvement are being discussed that would have never received consideration had this final line not been crossed.

This wasn't an issue that should have been pushed by the AANA. All agree that academic programs are underfunded in general and reimbursement needs to increase. In trying to halt the progress that the ASA has made over the past several years on this issue (and this effort was SOLELY initiated and funded by the ASA yet could have yielded great benefits to the AANA), the AANA took a step towards trying to find the lowest common denominator for residents and SRNA's to train under. If the AANA is successful, it will keep academic programs underfunded, understaffed, and unattractive to strong physician candidates looking at academic practice whose knowledge, research, and teaching abilities would have directly benefitted both resident and SRNA education.

CMS specifically narrowed the reimbursement issue to resident physicians because it did not consider midlevel provider education in ANY field in this policy review. There was no support for doubling SRNA reimbursement because there was NO PROVISION IN THE ORIGINAL CMS GUIDELINES OR THE RESPONSE as this was a CMS determined physician issue and applies solely to physicians in this legislation.

Once again, let me review the shortsightedness of the AANA:

A doubling of physician resident reimbursement does not suddenly make it unattractive to train SRNA's. Each program has ACGME limits to the number of resident physicians it can train based on its ability to provide time for educational efforts, ability to limit total training time each week, and adequate case numbers, in particular subspecialty case numbers. A program has to apply to expand its class sizes but only gets reviewed for expansion/contraction every 2-4 years and only by 1-5 residents per class, NOT 100%. There are currently NO LIMITS on the number of SRNA's that a program can enroll to train and help with work issues.

Programs that have a significant number of SRNA's cannot suddenly replace all of that man (and woman) power with a resident pool that isn't as readily available as the AANA thinks, and if it were to try, it is likely that the CRNA's there would walk out in protest, leaving an academic program with even more shortages to deal with. Academics want to be academics and not have to run their own cases all day and all night and both physicians and nurses work to help the hospital, each other, and the academic physicians whose work allows our field to continue to evolve and refine itself.

IF the AANA wanted to espouse the SRNA reimbursement issue in earnest, it could have joined forces with the ASA, jointly espoused the need for fair reimbursement of physician resident training cases, hoped for a revision to the CMS policy for physicians, then pushed for SRNA reimbursement equality with the ASA side by side with the precedent already set in CMS policy for physician residents. A win-win situation for academic programs and the AANA, especially for programs that cannot meet ACGME training standards, but still train SRNA's as well as programs with dual training programs.

This was what the ASA had thought was agreed to since CMS would only review the physician training aspect of each specialty's reimbursement schedule. The AANA wanted to expand the issue to include SRNA's, but that additional package would have made it LESS appealing to CMS to alter the policy just by looking at how much more it would cost Medicare/Medicaid. What the ASA did not expect was a behind the doors attempt to subvert their efforts. In the worst, WORST case scenario for the AANA, the ASA would achieve its goal of doubling resident reimbursement, CMS refuses to reconsider SRNA reimbursement schedules, and the AANA could then go to court to argue that since SRNA's participate to the same degree in cases on rotations with physician residents, they are being unfairly discriminated against by CMS. This would force CMS to revise the SRNA reimbursement policy, with a precedent already set, and not knock physician resident reimbursement down to 50%, because the threat would then exist that the ASA would likewise file suit for discriminatory practice for its physicians in training compared to other specialties.

Why do we not just go to court now? We are trying to stay in good standing with CMS and not develop an acrimonious relationship that would lean CMS away from other anesthesiology related issues. Other specialties have a low threshhold for litigation and it has made CMS less pliable to their issues.

This isn't rocket science. This was discussed over and over by ASA and AANA reps and if the AANA decided to travel their own route to support its trainees and not support the ASA's residents, there was no need to try to sabotage the ASA's efforts. The general feeling I get from academic program reps is that enough is enough. They feel that they have worked hard to make the atmosphere as unified as possible, all the while the AANA, while rightfully pushing for its membership's goals, continues to try to reduce physician training and reimbursement issues.

Instead of accomplishing its goal of making CRNA/SRNA presence more attractive, the AANA has done exactly the opposite. Class sizes are being reevaluated by every program this fall and growth in trainee numbers will be looked at on the resident side in detail. The AANA has also provided an impetus for the utilization of AA's as a more viable alternative and this would have been/will be discussed at the ASA in Atlanta. Some programs are now providing locums contracts to private practice anesthesiologists with creative financing and insurance coverage that allows the hospital to pay the anesthesiologist a minimum stipend while still making it attractive for the physician to cover cases at these academic programs and now cheaper (to the hospital) than paying a CRNA. More alternatives to CRNA/SRNA involvement are being discussed that would have never received consideration had this final line not been crossed.

This wasn't an issue that should have been pushed by the AANA. All agree that academic programs are underfunded in general and reimbursement needs to increase. In trying to halt the progress that the ASA has made over the past several years on this issue (and this effort was SOLELY initiated and funded by the ASA yet could have yielded great benefits to the AANA), the AANA took a step towards trying to find the lowest common denominator for residents and SRNA's to train under. If the AANA is successful, it will keep academic programs underfunded, understaffed, and unattractive to strong physician candidates looking at academic practice whose knowledge, research, and teaching abilities would have directly benefitted both resident and SRNA education.

:clap: :clap: :clap:

I'm sure glad there are other politically active and knowledgable out there. That was a SUPERB post.

I have way too much time on my hands in private practice, jwk.

CMS specifically narrowed the reimbursement issue to resident physicians because it did not consider midlevel provider education in ANY field in this policy review. There was no support for doubling SRNA reimbursement because there was NO PROVISION IN THE ORIGINAL CMS GUIDELINES OR THE RESPONSE as this was a CMS determined physician issue and applies solely to physicians in this legislation.

Once again, let me review the shortsightedness of the AANA:

A doubling of physician resident reimbursement does not suddenly make it unattractive to train SRNA's. Each program has ACGME limits to the number of resident physicians it can train based on its ability to provide time for educational efforts, ability to limit total training time each week, and adequate case numbers, in particular subspecialty case numbers. A program has to apply to expand its class sizes but only gets reviewed for expansion/contraction every 2-4 years and only by 1-5 residents per class, NOT 100%. There are currently NO LIMITS on the number of SRNA's that a program can enroll to train and help with work issues.

Programs that have a significant number of SRNA's cannot suddenly replace all of that man (and woman) power with a resident pool that isn't as readily available as the AANA thinks, and if it were to try, it is likely that the CRNA's there would walk out in protest, leaving an academic program with even more shortages to deal with. Academics want to be academics and not have to run their own cases all day and all night and both physicians and nurses work to help the hospital, each other, and the academic physicians whose work allows our field to continue to evolve and refine itself.

IF the AANA wanted to espouse the SRNA reimbursement issue in earnest, it could have joined forces with the ASA, jointly espoused the need for fair reimbursement of physician resident training cases, hoped for a revision to the CMS policy for physicians, then pushed for SRNA reimbursement equality with the ASA side by side with the precedent already set in CMS policy for physician residents. A win-win situation for academic programs and the AANA, especially for programs that cannot meet ACGME training standards, but still train SRNA's as well as programs with dual training programs.

This was what the ASA had thought was agreed to since CMS would only review the physician training aspect of each specialty's reimbursement schedule. The AANA wanted to expand the issue to include SRNA's, but that additional package would have made it LESS appealing to CMS to alter the policy just by looking at how much more it would cost Medicare/Medicaid. What the ASA did not expect was a behind the doors attempt to subvert their efforts. In the worst, WORST case scenario for the AANA, the ASA would achieve its goal of doubling resident reimbursement, CMS refuses to reconsider SRNA reimbursement schedules, and the AANA could then go to court to argue that since SRNA's participate to the same degree in cases on rotations with physician residents, they are being unfairly discriminated against by CMS. This would force CMS to revise the SRNA reimbursement policy, with a precedent already set, and not knock physician resident reimbursement down to 50%, because the threat would then exist that the ASA would likewise file suit for discriminatory practice for its physicians in training compared to other specialties.

Why do we not just go to court now? We are trying to stay in good standing with CMS and not develop an acrimonious relationship that would lean CMS away from other anesthesiology related issues. Other specialties have a low threshhold for litigation and it has made CMS less pliable to their issues.

This isn't rocket science. This was discussed over and over by ASA and AANA reps and if the AANA decided to travel their own route to support its trainees and not support the ASA's residents, there was no need to try to sabotage the ASA's efforts. The general feeling I get from academic program reps is that enough is enough. They feel that they have worked hard to make the atmosphere as unified as possible, all the while the AANA, while rightfully pushing for its membership's goals, continues to try to reduce physician training and reimbursement issues.

Instead of accomplishing its goal of making CRNA/SRNA presence more attractive, the AANA has done exactly the opposite. Class sizes are being reevaluated by every program this fall and growth in trainee numbers will be looked at on the resident side in detail. The AANA has also provided an impetus for the utilization of AA's as a more viable alternative and this would have been/will be discussed at the ASA in Atlanta. Some programs are now providing locums contracts to private practice anesthesiologists with creative financing and insurance coverage that allows the hospital to pay the anesthesiologist a minimum stipend while still making it attractive for the physician to cover cases at these academic programs and now cheaper (to the hospital) than paying a CRNA. More alternatives to CRNA/SRNA involvement are being discussed that would have never received consideration had this final line not been crossed.

This wasn't an issue that should have been pushed by the AANA. All agree that academic programs are underfunded in general and reimbursement needs to increase. In trying to halt the progress that the ASA has made over the past several years on this issue (and this effort was SOLELY initiated and funded by the ASA yet could have yielded great benefits to the AANA), the AANA took a step towards trying to find the lowest common denominator for residents and SRNA's to train under. If the AANA is successful, it will keep academic programs underfunded, understaffed, and unattractive to strong physician candidates looking at academic practice whose knowledge, research, and teaching abilities would have directly benefitted both resident and SRNA education.

Well said UT.

No counterpoints?

I'm a resident in a program w/o CRNA. During my prelim year I did a 2wk rotation in anesthsia department. What I saw the relationship between CRNA (>30 of them) and anesthsiology MD (~5) was shocking. The CRNA would be sitting at one end of table and MD would be at the other end during the conference. As out-numbered as they are, they didn't have much "vocal" power either. In another case, I saw a senior CRNA actually told the director of anesthsiology and me, the rotator to get out of her room because the teaching was too loud.

jetproppilot, I enjoy your post on this forum. You give us valuable insights on anesthesiology, in knowledge and practice. However, I have to point out one of biggest problem I see in your posts regarding CRNA:

CRNA are NOT your friends. They are your workers.

In general, anesthesiologists are most laid-back MDs. CRNA are most vocal (mostly female, in their prime years). When you have two groups of exactly opposite people like this, you are bound to have problem, especially when you are out-numbered like the one I mentioned.

I'm telling you, it's bad there. So bad that it's a shame to be a MD anesthesiologist.

True, CRNA are your colleagues, they do intubation, they sit in the case. However, they are NOT MDs, they are NURSES. Just like scrub nurse, circulating nurses assist surgeons. W/o them, surgeons can't do a case. Surgeons never consider scrub nurses equal, nor do scrub nurses ever DARE to ask for equalities to surgeons.

Why?

Two reasons stand out in my mind: 1st, I have mentioned, personality. Anesthesiologists are not aggressive enough, especially with older generation FMGs. 2nd, most importantly, anesthesiologists use CRNA to take more calls, to run more cases. Gradually, they lose their authority and RESPECT among people working for them because they get TOO LAZY and GREEDY.

In a private practice, as jetproppilot often mentions, CRNA works with or for anesthesiologists. Sure, it's because they get paid more when MDs get paid more as a group. Profit is aligned. As a whole, CRNA organization is vocal to get rid of MD supervision.

It's a constant battle. It's not a battle to be lost.

I say end it all, by eliminating CRNA participation of organized group. When a CRNA is hired, first thing on the contract, is forbiding any participation of CRNA organization, period. If they want to have a job, they have to be an obedient worker. If they refuse, hire someone. If there are no CRNA willing to take on the job, hire AA, or start to train different groups of "technicians". After all, MDs have hiring power, not CRNA.

Be vocal, fight this battle. Anyone who doesn't see the risk of CRNA with growing power, please email me. I'd be happy to forward you the hospital I rotated and you should go and check it out.

I'm a resident in a program w/o CRNA. During my prelim year I did a 2wk rotation in anesthsia department. What I saw the relationship between CRNA (>30 of them) and anesthsiology MD (~5) was shocking. The CRNA would be sitting at one end of table and MD would be at the other end during the conference. As out-numbered as they are, they didn't have much "vocal" power either. In another case, I saw a senior CRNA actually told the director of anesthsiology and me, the rotator to get out of her room because the teaching was too loud.

jetproppilot, I enjoy your post on this forum. You give us valuable insights on anesthesiology, in knowledge and practice. However, I have to point out one of biggest problem I see in your posts regarding CRNA:

CRNA are NOT your friends. They are your workers.

In general, anesthesiologists are most laid-back MDs. CRNA are most vocal (mostly female, in their prime years). When you have two groups of exactly opposite people like this, you are bound to have problem, especially when you are out-numbered like the one I mentioned.

I'm telling you, it's bad there. So bad that it's a shame to be a MD anesthesiologist.

True, CRNA are your colleagues, they do intubation, they sit in the case. However, they are NOT MDs, they are NURSES. Just like scrub nurse, circulating nurses assist surgeons. W/o them, surgeons can't do a case. Surgeons never consider scrub nurses equal, nor do scrub nurses ever DARE to ask for equalities to surgeons.

Why?

Two reasons stand out in my mind: 1st, I have mentioned, personality. Anesthesiologists are not aggressive enough, especially with older generation FMGs. 2nd, most importantly, anesthesiologists use CRNA to take more calls, to run more cases. Gradually, they lose their authority and RESPECT among people working for them because they get TOO LAZY and GREEDY.

In a private practice, as jetproppilot often mentions, CRNA works with or for anesthesiologists. Sure, it's because they get paid more when MDs get paid more as a group. Profit is aligned. As a whole, CRNA organization is vocal to get rid of MD supervision.

It's a constant battle. It's not a battle to be lost.

I say end it all, by eliminating CRNA participation of organized group. When a CRNA is hired, first thing on the contract, is forbiding any participation of CRNA organization, period. If they want to have a job, they have to be an obedient worker. If they refuse, hire someone. If there are no CRNA willing to take on the job, hire AA, or start to train different groups of "technicians". After all, MDs have hiring power, not CRNA.

Be vocal, fight this battle. Anyone who doesn't see the risk of CRNA with growing power, please email me. I'd be happy to forward you the hospital I rotated and you should go and check it out.

You're a little over the top with your opinions (the word "rambling" comes to mind) especially considering your EXTREMELY limited exposure to CRNA's. (wow, 2 weeks) Although I don't doubt your observations of this particular group, I can tell you that most anesthesia groups with MD's, CRNA's, and AA's work very well together. The group you describe is not typical in my experience, nor is your description of CRNA's (a bunch of old ladies? c'mon). I'm sure JPP would agree, and he and I together have seen a whole lot more than you have.

Do I have a problem with CRNA's as a professional organization? Absolutely. Do I have a problem with individual CRNA's in my group on a day to day basis? No I do not. Sure, the anesthetists are usually the employees (although there are MD's working for CRNA groups). But that doesn't mean that there can't be professional respect going both ways.

As far as your "hiring requirements" - good luck. "Obedient worker"??? Give me a break. Forbid participation in an organized group? Not even possible. You have no control over this, the requirement is probably illegal, and in order to maintain their certification and licensure, CRNA's need AANA-approved CME's. Guess what? You, and groups that might share a philosophy such as yours, will be standing around scratching your ass trying to figure out why you can't hire or retain good quality anesthetists, while groups that value their anesthetist employees will reap the benefits.

I fully understand most of the issues involved here, political, professional, or otherwise far more than you do, as does JPP. I know there are strong opinions on this board about CRNA's and MD's and even AA's. Unlike you, most of them are grounded in some EXPERIENCE from which to form those opinions.

And one last thing - as an AA, I would preferred to be hired by a group that values my services and capabilities. Hiring me as a backup or second choice because you're pissed off at CRNA's won't thrill me, and if your overall attitude of all non-physicians (nurses, CRNA's, technicians, AA's, or otherwise) is what you present on this board, good luck on your hiring. As long as you view anesthetists of either variety as just nurses or technicians, your list of employees/colleagues will be extremely short or non-existent.

First of all, you as an AA is welcomed to make a comment here. I have no problem with it. So feel free to express your anger/frustration/or whatsoever towards your SUPERIOR. Yes, you heard it right, MD anethesiologists are your SUPERIORS, respect it, and accept it. Medicine is a field of hierarchy. If you are a nurse, no matter how good you are at placing IV, a-line, intubate, you are a nurse, period. If you feel you deserve more respect than a MD, please go through 4 yrs of college, 4 years of medical school, 4 years of residency before you can make a sound argument, REGARDLESS how much experience you have in NURSING.

I'll respect you as a NURSE because you have the skill we need, not because the years of academic education you have. Know your limit, respect your superior, or you won't find a job.

As for as "while groups that value their anesthetist employees will reap the benefits", it is exactly the point I'm trying to make to my fellow future anesthesiologists. Work hard, know your trade, and be reasonable instead of greedy. It's not all about profit. It's also about respect among your fellow MD colleagues and your patients. Talk like a MD, act like one.

Join your organization, voice your opinions. No, I'm not being militant about this. We should all respect our colleagues, regardless of their position, MD, CRNA, AA, floor nurses. However, we won't tolerate bad employees, or employees in a lousy organization.

The stereotype of lazy, passive anesthesiologists are changing, especially, as more and more AMG getting into the field. If we didn't do our part, CRNAs as a whole (no, I didn't mean old ladies, I say, females in their prime, 30-50yrs with all the energy in the world to fight for their independent practice right) will.

My exposure with CRNA is short. Any longer I'd be ashamed to be a MD in the department even as a rotator. It reflects the disaster it could be heading to if anethesiologists aren't doing something about it.





You're a little over the top with your opinions (the word "rambling" comes to mind) especially considering your EXTREMELY limited exposure to CRNA's. (wow, 2 weeks) Although I don't doubt your observations of this particular group, I can tell you that most anesthesia groups with MD's, CRNA's, and AA's work very well together. The group you describe is not typical in my experience, nor is your description of CRNA's (a bunch of old ladies? c'mon). I'm sure JPP would agree, and he and I together have seen a whole lot more than you have.

Do I have a problem with CRNA's as a professional organization? Absolutely. Do I have a problem with individual CRNA's in my group on a day to day basis? No I do not. Sure, the anesthetists are usually the employees (although there are MD's working for CRNA groups). But that doesn't mean that there can't be professional respect going both ways.

As far as your "hiring requirements" - good luck. "Obedient worker"??? Give me a break. Forbid participation in an organized group? Not even possible. You have no control over this, the requirement is probably illegal, and in order to maintain their certification and licensure, CRNA's need AANA-approved CME's. Guess what? You, and groups that might share a philosophy such as yours, will be standing around scratching your ass trying to figure out why you can't hire or retain good quality anesthetists, while groups that value their anesthetist employees will reap the benefits.

I fully understand most of the issues involved here, political, professional, or otherwise far more than you do, as does JPP. I know there are strong opinions on this board about CRNA's and MD's and even AA's. Unlike you, most of them are grounded in some EXPERIENCE from which to form those opinions.

And one last thing - as an AA, I would preferred to be hired by a group that values my services and capabilities. Hiring me as a backup or second choice because you're pissed off at CRNA's won't thrill me, and if your overall attitude of all non-physicians (nurses, CRNA's, technicians, AA's, or otherwise) is what you present on this board, good luck on your hiring. As long as you view anesthetists of either variety as just nurses or technicians, your list of employees/colleagues will be extremely short or non-existent.

Just to answer private messages regarding where this institution is located. It's in southern california, affiliated with one of academic centers in the area. The department chair of the academic center had enough with CRNA a few years ago, and fired all of his CRNA (from what I was told). Now his residents have to work pretty hard due to heavy case loads. However, they have solid training and are well-respected.

I'm a resident in a program w/o CRNA. During my prelim year I did a 2wk rotation in anesthsia department. What I saw the relationship between CRNA (>30 of them) and anesthsiology MD (~5) was shocking. The CRNA would be sitting at one end of table and MD would be at the other end during the conference. As out-numbered as they are, they didn't have much "vocal" power either. In another case, I saw a senior CRNA actually told the director of anesthsiology and me, the rotator to get out of her room because the teaching was too loud.

jetproppilot, I enjoy your post on this forum. You give us valuable insights on anesthesiology, in knowledge and practice. However, I have to point out one of biggest problem I see in your posts regarding CRNA:

CRNA are NOT your friends. They are your workers.

In general, anesthesiologists are most laid-back MDs. CRNA are most vocal (mostly female, in their prime years). When you have two groups of exactly opposite people like this, you are bound to have problem, especially when you are out-numbered like the one I mentioned.

I'm telling you, it's bad there. So bad that it's a shame to be a MD anesthesiologist.

True, CRNA are your colleagues, they do intubation, they sit in the case. However, they are NOT MDs, they are NURSES. Just like scrub nurse, circulating nurses assist surgeons. W/o them, surgeons can't do a case. Surgeons never consider scrub nurses equal, nor do scrub nurses ever DARE to ask for equalities to surgeons.

Why?

Two reasons stand out in my mind: 1st, I have mentioned, personality. Anesthesiologists are not aggressive enough, especially with older generation FMGs. 2nd, most importantly, anesthesiologists use CRNA to take more calls, to run more cases. Gradually, they lose their authority and RESPECT among people working for them because they get TOO LAZY and GREEDY.

In a private practice, as jetproppilot often mentions, CRNA works with or for anesthesiologists. Sure, it's because they get paid more when MDs get paid more as a group. Profit is aligned. As a whole, CRNA organization is vocal to get rid of MD supervision.

It's a constant battle. It's not a battle to be lost.

I say end it all, by eliminating CRNA participation of organized group. When a CRNA is hired, first thing on the contract, is forbiding any participation of CRNA organization, period. If they want to have a job, they have to be an obedient worker. If they refuse, hire someone. If there are no CRNA willing to take on the job, hire AA, or start to train different groups of "technicians". After all, MDs have hiring power, not CRNA.

Be vocal, fight this battle. Anyone who doesn't see the risk of CRNA with growing power, please email me. I'd be happy to forward you the hospital I rotated and you should go and check it out.

NIce post Kail, and I respect your constructive criticism. Not sure I agree with it though. And nice counterpoint post, JWK.

For now, though, I'm gonna just sit back and enjoy the great posts on this thread.

Guess that 15-20 minute drive outta New Orleans on the Tuesday after the storm with my 2 year old in his babyseat behind me not knowing whether I was gonna be able to get us to the only entrance ramp to the only bridge outta the city has taken the wind outta my sails a little...makes this controversy seem silly, all things considered.

First of all, you as an AA is welcomed to make a comment here. I have no problem with it. So feel free to express your anger/frustration/or whatsoever towards your SUPERIOR. Yes, you heard it right, MD anethesiologists are your SUPERIORS, respect it, and accept it. Medicine is a field of hierarchy. If you are a nurse, no matter how good you are at placing IV, a-line, intubate, you are a nurse, period. If you feel you deserve more respect than a MD, please go through 4 yrs of college, 4 years of medical school, 4 years of residency before you can make a sound argument, REGARDLESS how much experience you have in NURSING.

I'll respect you as a NURSE because you have the skill we need, not because the years of academic education you have. Know your limit, respect your superior, or you won't find a job.

Kailiedu, posts like this are gonna get this thread shut down in a heartbeat. We've managed to keep this discussion relatively civilized so far, so let's please back off the nurse bashing so we can have a productive dialogue. If the thread gets locked we will lose UT's wise words in that great post to the depths of the SDN Forums!

Thanks andy, for pointing out the possibility of my post leading to the shut-down of this entire threat. I've seen it happen. I used to wonder why MD/CRNA/AA argue about this all the time.

Trust me, i'd rather enjoy reading my Morgan then spending time writing all this. but, feel obligated to share what i've seen to the rest of my fellow residents. it's our future, our livelihood we're talking about, to say the least. On the top of that, we do have our pride to work this hard through undergrad, through MCAT, sacrifice much to go through medical school and years of residency.

I respect nurses. However, I do NOT consider them to be equal with MDs. (try to bring up this equality topic to general surgeons, they would not hesitate to yell scrub nurses out of their ORs)

The title of MD carries our professional pride, our value of education, our committment to patient care, our ability to take responsibility when the rest of health care profession stays aside.

If we are afraid of our voices being shut down, ignored, or argued against, we're losing our confidence, our pride, the very essence of being a physician.

So please, do NOT shut down this threat. Let them CRNA/AA look at us, proud generation of anesthesiologists.

I am sure, the respect will be, and has to been earned.

Trust me, i'd rather enjoy reading my Morgan then spending time writing all this. but, feel obligated to share what i've seen to the rest of my fellow residents

So please, do NOT shut down this threat. Let them CRNA/AA look at us, proud generation of anesthesiologists.

I am sure, the respect will be, and has to been earned.

Just a couple points and I'll quit fueling this particular fire.

1) Two weeks in a lousy practice as your only exposure to CRNA's isn't much to share or on which to base such strong opinions;

2) There's a difference between pride in your profession and being pompous;

3) Respect is definitely earned, not bestowed by degree. It goes both ways, not one.

Kailiedu, posts like this are gonna get this thread shut down in a heartbeat. We've managed to keep this discussion relatively civilized so far, so let's please back off the nurse bashing so we can have a productive dialogue. If the thread gets locked we will lose UT's wise words in that great post to the depths of the SDN Forums!

Speaking of which, does anyone know what happens to old posts that go past your 500 post count? There are a few old posts I want to get at to clip and save for posterity.

Speaking of which, does anyone know what happens to old posts that go past your 500 post count? There are a few old posts I want to get at to clip and save for posterity.

OK, I feel like a stalker, but here ya go:

http://forums.studentdoctor.net/search.php?searchid=1262043

That should start back with your first post. I just did an advanced search on your name, and changed the "sort results" option from descending to ascending order. Hope that helps!

OK, I feel like a stalker, but here ya go:

http://forums.studentdoctor.net/search.php?searchid=1262043

That should start back with your first post. I just did an advanced search on your name, and changed the "sort results" option from descending to ascending order. Hope that helps!

Figures it would be something as simple as "go to first post". Thanks, and why are you stalking me????? :scared:

Figures it would be something as simple as "go to first post". Thanks, and why are you stalking me????? :scared:

Rock stars have stalkers. Its part of the gig.

JWK, I believe he was referring to a teaching hospital he rotated at during his prelim year not a private practice.



"During my prelim year I did a 2wk rotation in anesthsia department"


Regardless - by his own admision, he has two weeks of "experience" with CRNA's, and most of that I would assume was NOT actually working with the CRNA's. Pretty strong opinions for such limited contact, IMHO.

Look, my 2wks rotation in this anesthesia department is more than enough to show me the kind of disaster it could lead to if we let CRNA's aggressiveness continue. Actually, I did meet a few nicer CRNAs in the department. However, it's not the nice ones I'm concerned of. The older ones, who think they know what they are doing and don't need MD supervision are the ones who are rude and aggressive and dis-respectful to superiors.

Do u think if I stayed in the department I would see the magic change of aggressive behaviors among these CRNA? No. It won't negate what I have seen even in short period of two wks.

It should have never happen, not even for one day.

Imagine, a scrub nurse telling a general surgeon to get our of HIS/HER room, it would be the end of his career.

Now, for you, please be thoughtful before you post your msgs. There is a logic why I quote my 2wks of rotation. The fact you keep dwelling on this simply shows the lack of logic clear deductive reasoning process in your thinking.

College education, medical school education, residency training give you not only the medical knowledge, more importantly, enables you to think, to reason.

I'm afraid that's something you don't have.











"During my prelim year I did a 2wk rotation in anesthsia department"




Regardless - by his own admision, he has two weeks of "experience" with CRNA's, and most of that I would assume was NOT actually working with the CRNA's. Pretty strong opinions for such limited contact, IMHO.

It reflects the disaster it could be heading to if anethesiologists aren't doing something about it.

Dude, I've been hearing this since residency (1992-1996). Even went to the state capital to lobby against whatever the then-current-disaster-waiting to happen was.

Now almost nine years in practice, I just dont see or feel the threat that the residents or newly-emerging anesthesiologists feel. Complacency? Maybe.

Or is it that the residents/newly-emerging anesthesiologists are reacting to "hype" created by the academic sector?

I've been where you are now. And felt like you do now. Nine years later, I'm still comfortable, my income is still, uh, more than I thought I'd ever make, I still like anesthesia, and our group is successful, fully staffed, with a stack of applications of people who want to work with us. This success didnt come by telling CRNAs "you're a subordinate, you're here because of me", blah blah blah.

If I would've bought into this "the-sky-is-falling" philosophy when I emerged from residency, the enjoyment of my specialty/life would've been blunted for the last NINE years.

I feel different now than I did when I was a resident...an evolution resultant from my experiences. This "The-CRNAS-Are-Gonna-Take-Over-The-World" topic is overplayed, in my opinion.

I've yet to work in a hospital that demands anesthesiologists in their hospital. And in the scenerios where there are no anesthesiologists (rural), I've yet to meet a CEO or surgeon who works there who wouldnt want an anesthesiologist if they could recruit one.

Bottom line? Pay attention to the ongoings. But dont obsess about it. If you do, you'll regret the time you lost when you look back over ten years of your career.

ANd consider that your current viewpoints, which are heavily influenced by academic physicians and a very inefficient, unorganized, poorly-informed-about-real-life anesthesia practices/relationships institution, may very well change when you are involved in a well oiled, safe, efficient private practice group that uses the team-approach model.

jwk - very fair post. tough - you've got to be kidding, only 7 CRNAs.

k, ever watched killbill2? the part where bill says, "i've never been nice in my whole life, but i'll try my best ... to be sweet."

kelly, a concerned krankenschwester

Yeah or otherwise oldmandave may come and try to ban you from the forum :rolleyes:


I am so laughing my @$$ off at this! :barf:

This thread, although contentious at times, is going pretty darned well for the most part. Important & heated issues are being hashed through in a surprisingly (for SDN) professional demeanor. There is no way I would shut down such a meaty/hefty thread...but, were individuals to descend to childish name calling or violate TOS, I would not hesitate to contact them individually. Afterall, like it or not - that is my job here.

I don't know how much independent practice right CRNA had 10 yrs ago, however, I do know 10yrs down the road, they have been granted to practice independently in a few states.

Do you call it a progress from CRNA's perspective? I think so.

Do you consider it a partial defeat of national ASA? I think so, too.

Why did this happen, a nurse telling MD to step-aside?

It's easy to forget about the conflict between anesthesiologists and CRNAs when you are in private practice, enjoying your private life and healthy paycheck. When everyone of us is only looking out for our own interest, easy-schedule, no calls, financial gain, no wonder CRNA can use its organizational power to "divide-and-conquer":

The falling of a few states to CRNA.

Please look beyond today, beyond what's in your private practice.

Even you consider CRNA your friends (trust me, I'd like to think the same, too). With the aggressive nature of CRNA organization, I would be very clear when interacting with these friends,

"know your limit, and respect your superior"

Only after their aggressive behavior are warned and checked, we can rest assured and be friends. After all, friendship means mutual respect.

An anesthesiologist has to realize, CRNA is the only nursing group who has gone so far to be granted most financial rewards and privilage in nursing field. It's also the only nursing group who dare to fight "turf-war" with MDs.

Think about it, this battle is ridiculous to begin with.

Kaili - CRNAs practice independently in all 50 states.

I don't know how much independent practice right CRNA had 10 yrs ago, however, I do know 10yrs down the road, they have been granted to practice independently in a few states.

Do you call it a progress from CRNA's perspective? I think so.

Do you consider it a partial defeat of national ASA? I think so, too.

Why did this happen, a nurse telling MD to step-aside?

It's easy to forget about the conflict between anesthesiologists and CRNAs when you are in private practice, enjoying your private life and healthy paycheck. When everyone of us is only looking out for our own interest, easy-schedule, no calls, financial gain, no wonder CRNA can use its organizational power to "divide-and-conquer":

The falling of a few states to CRNA.

Please look beyond today, beyond what's in your private practice.

Even you consider CRNA your friends (trust me, I'd like to think the same, too). With the aggressive nature of CRNA organization, I would be very clear when interacting with these friends,

"know your limit, and respect your superior"

Only after their aggressive behavior are warned and checked, we can rest assured and be friends. After all, friendship means mutual respect.

An anesthesiologist has to realize, CRNA is the only nursing group who has gone so far to be granted most financial rewards and privilage in nursing field. It's also the only nursing group who dare to fight "turf-war" with MDs.

Think about it, this battle is ridiculous to begin with.

I'm not disagreeing with your opinions on the aggressiveness of the AANA, and I do feel political groups working in our favor is necessary.
I do not feel, however, that one's political stance has to infiltrate the operating room. You are making the MD-CRNA "battle" personal, and you do not have to.

If you are a republican, do you scorn people that are democrat? I cant think of a bigger political battle than that one, and yet American people forge personal and working relationships independent of party loyalty.
Lets say I'm republican and I COMPLETELY disagree with many democratic standings. Lets say the democrats endorsed higher taxation for "high" wage earners. THat would be very threatening to me, right? So based on this hypothetical situation, should I select only republican friends/workers/spouse?

Its great that you are passionate about your cause. Avoiding bringing your opinions to the personal level will benefit you in the long run.

So based on this hypothetical situation, should I select only republican friends/workers/spouse?
That's actually not such a bad idea. :D

"Its great that you are passionate about your cause. Avoiding bringing your opinions to the personal level will benefit you in the long run."

Jetpropilot, thanks for pointing it out. I do appreciate this constructive advise: avoid direct confrontation with any particular CRNA at workplace.

And I do think CRNAs are skillful technicians who deserves our respect.

However, when they forget their place and act with aggression towards MD anesthesiologists (such as telling the director of anesthesia department to get out of her room), I will no doubt bring her to the example of aggressive CRNA being fired from her job in no time, regardless how many years of experience she has in CRNA.

It takes guts to do this against pressure. It has to been done, however.

An idea came to my mind, instead of let CRNA organization certifying CRNA, why doesn't ASA create a sub-organization that provide training, and certifying "CRNA"s? This solves certification problem, but also give ASA/anesthesiologists control of CRNA. Private/Public anesthesiology group will only hire these CRNAs, submitting to policy/restriction set by ASA.

Premature thought, what do you guys think?

enlighten me, how do AA and CRNA differ, in terms of education, organization, and most importantly, aggressive demand characteristics?



I like it.

How about more AA's in the OR as well? I believe AA's are superb providers. Their training although shorter than MD training follows the medical model. I have worked with many of them and it was a joy.

[QUOTE=kailieduHowever, when they forget their place and act with aggression towards MD anesthesiologists (such as telling the director of anesthesia department to get out of her room), I will no doubt bring her to the example of aggressive CRNA being fired from her job in no time, regardless how many years of experience she has in CRNA.

It takes guts to do this against pressure. It has to been done, however.
[/QUOTE]

This is an entirely different ballgame, deserving of a pink slip. Only in an academic behemoth would that be tolerated.

It takes guts to do this against pressure. It has to been done, however.

An idea came to my mind, instead of let CRNA organization certifying CRNA, why doesn't ASA create a sub-organization that provide training, and certifying "CRNA"s? This solves certification problem, but also give ASA/anesthesiologists control of CRNA. Private/Public anesthesiology group will only hire these CRNAs, submitting to policy/restriction set by ASA.



Enough is enough.
No one "lets" the AANA certify CRNAs. Seeing how it was decided back in the 1930s that Nurse Anesthesia is separate from Anesthesiology (and I'm sure that most ASA card-carrying members wish he or she could change this), just how do you propose to topple the AANA and bring CRNAs under the umbrella of the ASA's wing?





That silence you hear is a big fat....."Ain't gonna happen".

Do me a favor and email the AANA about your plan, give your reasons for your opinion, and outline your strategy and post their reply here on this board.

Your ignorance of anesthesia is astounding considering your pompus vocal outpouring here. By your own admission, you spent two lousy weeks in a bad situation and now you are spearheading your own campaign here. Tell me, two weeks into an OB rotation, do you think you had enough of a grasp on the OB world to try and run the show? Did they make you chief res after your two weeks? Two weeks is enough to have an opinion, but an informed opinion is another topic altogether. Until you have more experience in anesthesia and see how different programs / groups run, your experiences don't reflect the majority and it would be nice if you would realize this.
Comparing scrub nurses and surgeons to CRNAs and anesthesiologists is utterly absurd and shows your shallow depth of understanding of anesthesia personnel and politics. You got told to leave a room......Get over it.

One of our anesthesiologists was scheduled to have his spine fused, who did he pick to deliver his anesthesia? One of his MD partners??? Nope. He personally requested the delivery of anesthesia by a CRNA in the practice. 'Nuff said.

You and toughlife knock yourselves out here.

[QUOTE=rn29306]One of our anesthesiologists was scheduled to have his spine fused, who did he pick to deliver his anesthesia? One of his MD partners??? Nope. He personally requested the delivery of anesthesia by a CRNA in the practice. 'Nuff said. [QUOTE]

and what is the name of this physician?

[QUOTE=rn29306]One of our anesthesiologists was scheduled to have his spine fused, who did he pick to deliver his anesthesia? One of his MD partners??? Nope. He personally requested the delivery of anesthesia by a CRNA in the practice. 'Nuff said. [QUOTE]

and what is the name of this physician?


Each of us has stories to tell. He told his. I have mine. You are entitled to question this story at will, but I am not stupid enough to release the name of one of my attendings over the internet, especially when it concerns a surgery of his. Sorry, but I cannot comply UTSW.

I like it.

How about more AA's in the OR as well? I believe AA's are superb providers. Their training although shorter than MD training follows the medical model. I have worked with many of them and it was a joy.

Whoa, tough - you've actually worked with AA's? I'll have to rethink my whole opinion now..... ;)


As far as the difference between AA's and CRNA's - let me respond tomorrow when I have more time to type.

As a result, I have not seen many AAs (PAs trained in anesthesiology) at my institution in the OR. I have worked with them in surgery and medicine. They round with the medicine and surgery team and provide care for patients under the guidance of the attending or chief resident.


Just trying to clarify...Have you worked with AAs in the OR as delivering anesthesia or have you worked with medicine or surgical PAs either in the operating room on the surgeon's side of the BBB or rounding on patients?
From your post it seems like you are describing medicine or surgical PAs.
The education tracts for PAs and AAs are entirely different....

I think JWK is best qualified to do so. He is an AA and has been a long time contributor of this forum.

So JWK, if you are around, would you do the honors?

thanks,


P.S: I do know that the AANA is set against allowing AAs to increase their presence in the OR because they perceive them as competition against their CRNAs. As a result, I have not seen many AAs (PAs trained in anesthesiology) at my institution in the OR.
I have worked with them in surgery and medicine. They round with the medicine and surgery team and provide care for patients under the guidance of the attending or chief resident.

Here's a pretty good comparison of the two fields in general, although some of the numbers are out of date:

http://www.asahq.org/asarc/AA-CRNA_Comparison.pdf

The March, 2003 issue of the ASA Newsletter devoted it's cover topic to AA's.

http://www.asahq.org/Newsletters/2003/03_03/TOC_0303.html

AA's currently practice in 17 states and the District of Columbia. We are an approved anesthesia provider for Medicare (MD and CRNA are the other two), as well as TriCare, and the VA, so technically, an AA with a license in one state could work for the VA in any state, even one that doesn't license AA's.

In an anesthesia care team practice that utilizes both AA's and CRNA's, the job descriptions and compensation are identical. There are a handful of MD and AA-only practices, but the majority of practices that use AA's have CRNA's as well.

One correction and clarification needs to be made - AA's are NOT PA's trained in anesthesiology. Many refer to AA's as anesthesia PA's, but this is incorrect, although Georgia licenses their AA's as a specialty PA. AA's are a separate profession, with it's own set of certification and accreditation standards. In fact, PA's per se are not eligible for third-party reimbursement for actually administering anesthesia, since regulations specify MD, CRNA, or AA. You will occasionally find PA's working in pre-op and pain clinics, but it would be extremely rare to find one in the OR unless they have dual PA/AA certification.

I could bury you with info on this, so if anyone would like more info on AA's, please don't hesitate to PM me and I'll bury you in private. :laugh:

Requiring an added certification by the ASA for CRNAs to be hired into a group does not sound difficult at all. All MD anesthesiologists have to do is decide they will hire only those who have this added certification. CRNAs that don't comply will not be hired. Just like you cannot be hired as a nurse if you don't have an RN certificate.

Medicine and nursing are two separate fields, each with their own licensure. Of course this by itself is one of the huge disagreements between anesthesiologists and CRNA's. Lots of interesting arguments come into play here, including restraint of trade (although the AANA really only sees one side of that issue).

Somehow I doubt that requirement could be added - there is a difference between licensure and a private corporation (which the ASA is) expressing it's preferences.

And to an earlier question/post about CRNA's being admitted as Education Members of the ASA - in order to obtain such a membership, the applicant (whether AA or CRNA) must complete an application, have it signed by two active members of the ASA, AND sign the application under a statement that the applicant agrees with the Guidelines for the Ethical Practice of Anesthesiology and subscribes to the Anesthesia Care Team Statement of the ASA. That would probably explain why there are only 7 CRNA Educational Members.

.

let the force be with u

Nitecap, before I answer, let me ask the moderator if he'd like to put this into a separate thread, since these posts are getting kind of far removed from the original topic.

You pose some interesting questions which I'm more than happy to answer. I'll continue shortly...

Nitecap, before I answer, let me ask the moderator if he'd like to put this into a separate thread, since these posts are getting kind of far removed from the original topic.

You pose some interesting questions which I'm more than happy to answer. I'll continue shortly...


Cool.

Nitecap, before I answer, let me ask the moderator if he'd like to put this into a separate thread, since these posts are getting kind of far removed from the original topic.

You pose some interesting questions which I'm more than happy to answer. I'll continue shortly...


JWK,

Not too bad an idea...a lot of great discussion occuring in this thread. But with the title being such as it is, I wonder how many folks are missing out. Of course, there is the risk that by starting anew w/ descriptive title will bring out the trolls & flamers too.

Your call...

At least I enter the OR having started IV's, pushed meds, managed vented pt's. The PA students dont even know what a stop cock is much less 12 stopcocks tied together with 10 drips infusing thru them.

Mastering the Anesthesia machine is an ongoing task for myself. I couldnt even imagine having to learn even the basic hospital equipment such as pumps and gas supplies and just things that even that average Nursing assistant knows from just being in the hospital.


Not at all discrediting the wealth of other experiences you gain as an ICU nurse, but starting IV's, pushing meds, learning about the anesthesia machine, gas supplies, pumps, stopcocks with multiple drips, and all the other technical aspects takes about at most 5 months to achieve a decent level of experience... all very intuitive.

Now sensing when a pt is heading one way or another takes way longer... and it all comes with time no matter what your degree...

Oldmandave, good call. I think a new thread should be opened up with the topic at hand. I'll respond more when there is a focused topic.

JWK,

Not too bad an idea...a lot of great discussion occuring in this thread. But with the title being such as it is, I wonder how many folks are missing out. Of course, there is the risk that by starting anew w/ descriptive title will bring out the trolls & flamers too.

Your call...

New thread works for me - we definitely got sidetracked off the original ASA topic which was actually very important by itself.

I love when RNs state that they have experience in the ICU titrating drips, weaning vents, adjusting IABP, managed new heart transplants and taken care of VADs.... give me a break... who do you think gives the orders or writes the protocols for what you do? Do you think RNs initiate any of these medical decisions on their own?

I'd like to see the nurse who starts a patient on Vasopressin on their own.
I'd like to see the nurse who decides that CPAP is better than Pressure Controlled ventilation for a patient w/ bronchopleural fistulae on their own.
I'd like to see the nurse who places the IABP and then decides when to turn it off.
I'd like to see the nurse troubleshoot the VAD and manage a patient who has loss of the pneumatic drive and has a BP of 50/40 and is in CHF - on their own.

Let me help paraphrase your initial statement. Nurses see a lot of things at the bedside, and over time their knowledge base grows based on previous experiences/exposures but minimal understanding of the underlying issues. They see a patient on dopamine for BP support then think that dopamine is the best way to maintain BP... They see Zosyn and start believing that is the best way to treat pseudomonal infections... medicine is more than protocols and algorithms... medicine is more than turning levophed from 8mcg/min to 6mcg/min because a patients vascular tone is recovering from SIRS.

gimme a break... my wife was an ICU nurse for 12 years (until last year) and was very good at what she did, but she still came to me (even when i was a med student) to have me explain why and what and where...

go to med school if you want to practice medicine
go to CRNA school if you want to practice advanced nursing

:thumbup:

Excellent post that I and my colleagues wholeheartedly agree with.

I love when RNs state that they have experience in the ICU titrating drips, weaning vents, adjusting IABP, managed new heart transplants and taken care of VADs.... give me a break... who do you think gives the orders or writes the protocols for what you do? Do you think RNs initiate any of these medical decisions on their own?

I'd like to see the nurse who starts a patient on Vasopressin on their own.
I'd like to see the nurse who decides that CPAP is better than Pressure Controlled ventilation for a patient w/ bronchopleural fistulae on their own.
I'd like to see the nurse who places the IABP and then decides when to turn it off.
I'd like to see the nurse troubleshoot the VAD and manage a patient who has loss of the pneumatic drive and has a BP of 50/40 and is in CHF - on their own.

Let me help paraphrase your initial statement. Nurses see a lot of things at the bedside, and over time their knowledge base grows based on previous experiences/exposures but minimal understanding of the underlying issues. They see a patient on dopamine for BP support then think that dopamine is the best way to maintain BP... They see Zosyn and start believing that is the best way to treat pseudomonal infections... medicine is more than protocols and algorithms... medicine is more than turning levophed from 8mcg/min to 6mcg/min because a patients vascular tone is recovering from SIRS.

gimme a break... my wife was an ICU nurse for 12 years (until last year) and was very good at what she did, but she still came to me (even when i was a med student) to have me explain why and what and where...

go to med school if you want to practice medicine
go to CRNA school if you want to practice advanced nursing

Nice

I love when RNs state that they have experience in the ICU titrating drips, weaning vents, adjusting IABP, managed new heart transplants and taken care of VADs.... give me a break... who do you think gives the orders or writes the protocols for what you do? Do you think RNs initiate any of these medical decisions on their own?

I'd like to see the nurse who starts a patient on Vasopressin on their own.
I'd like to see the nurse who decides that CPAP is better than Pressure Controlled ventilation for a patient w/ bronchopleural fistulae on their own.
I'd like to see the nurse who places the IABP and then decides when to turn it off.
I'd like to see the nurse troubleshoot the VAD and manage a patient who has loss of the pneumatic drive and has a BP of 50/40 and is in CHF - on their own.

Let me help paraphrase your initial statement. Nurses see a lot of things at the bedside, and over time their knowledge base grows based on previous experiences/exposures but minimal understanding of the underlying issues. They see a patient on dopamine for BP support then think that dopamine is the best way to maintain BP... They see Zosyn and start believing that is the best way to treat pseudomonal infections... medicine is more than protocols and algorithms... medicine is more than turning levophed from 8mcg/min to 6mcg/min because a patients vascular tone is recovering from SIRS.

gimme a break... my wife was an ICU nurse for 12 years (until last year) and was very good at what she did, but she still came to me (even when i was a med student) to have me explain why and what and where...

go to med school if you want to practice medicine
go to CRNA school if you want to practice advanced nursing


The poster was comparing a seasoned ICU nurse to what he or she perceived as never-been-in-a-hospital-setting AA student when both end up in anesthesia school. No reference was made to medical students, MDs, or anything else. You missed the point in an attempt to quickly criticize nursing once again. Same goes for all that agreed with you.

I tried to PM you, but your mailbox is full. Thanks.

I love when RNs state that they have experience in the ICU titrating drips, weaning vents, adjusting IABP, managed new heart transplants and taken care of VADs.... give me a break... who do you think gives the orders or writes the protocols for what you do? Do you think RNs initiate any of these medical decisions on their own?

I'd like to see the nurse who starts a patient on Vasopressin on their own.
I'd like to see the nurse who decides that CPAP is better than Pressure Controlled ventilation for a patient w/ bronchopleural fistulae on their own.
I'd like to see the nurse who places the IABP and then decides when to turn it off.
I'd like to see the nurse troubleshoot the VAD and manage a patient who has loss of the pneumatic drive and has a BP of 50/40 and is in CHF - on their own.

Let me help paraphrase your initial statement. Nurses see a lot of things at the bedside, and over time their knowledge base grows based on previous experiences/exposures but minimal understanding of the underlying issues. They see a patient on dopamine for BP support then think that dopamine is the best way to maintain BP... They see Zosyn and start believing that is the best way to treat pseudomonal infections... medicine is more than protocols and algorithms... medicine is more than turning levophed from 8mcg/min to 6mcg/min because a patients vascular tone is recovering from SIRS.

gimme a break... my wife was an ICU nurse for 12 years (until last year) and was very good at what she did, but she still came to me (even when i was a med student) to have me explain why and what and where...

go to med school if you want to practice medicine
go to CRNA school if you want to practice advanced nursing


I can adjust VADS and IABP just as good if not better than any 1st or 2nd year anesthesia, IM resident. Though I def. can not insert one and have no desire to do so I can make balloon adjustments as well as VAD adjustments very well. Many Anesthesiologists run the case and may make VAD and Balloon adjustments in the OR but when the pt comes out and is in the ICU wks to months unless the Anesthesiologist is a critical care intensivist working in the ICU they make little if any device mgmt decisions. Come on now how often do you really make VAD changes, dont inflate yourself. At any facility that I have worked at though the Anesthesia MD may make VAD changes in the OR we all know it's either the surgery of TP cardio or VAd program coordinators that adjust the VAD most of the time

I have become quit an expert on the Debakey Medtech axial flow vad and will put my knowledge and experience to any resident. Im pretty competent managing hearmate I, thoratec, biomedicus and abiomed as well. I have studied probrably the same literature you have. I have managed many many VAD pt's, though not in OR. MOst of the time they crump post-op anyways and reg anesthesia is no where near unless they are bringing the pt back and still it is doubtful that anesthesia is going to be making any drastic VAD setting changes. Intra-op you have way more experience than I, but post op i can trouble shoot VAD related issues as well as many anesthesia residents. Anesthesia has little hands on with vads if any intra op in my experience, and when so they always collaborate with surgery or perfussion before pressing buttons, increasing flows or RPMS, switching drives or even manually pumping and changing filters if needed in emergencies.

Im my experience most anesthesia residents have no clue when It comes to the VAD. They may have a general understanding of how it works but they have no clue how to trouble shoot alarms, DisConnect pt and manually pump if needed, assess bladder filling to assess volume status, do flash tests to assess filling ect. Most of the time when receiving a pt from OR the balloon timing is totally off and needs adjustments anyway.

Again I understand that different facilities may have different services handling these issues so you may been the VAD GOD who knows. But most VAD pt's crump post-op and RN's manage VADS very well. Most VAD coordinators at facilities are RN's as well. I would rather the VAD coordinator RN make Vad changes sometimes rather than any MD. When your at the bedside 12hrs a day 4 x a week with a VAD or balloon pt you get to know that pt and his device very well and are able to recognize subtle changes either in the pt or device itself. Its all about experience man, either you have it, you want it or you are trying to get it. Your medical knowledge makes no difference when you are managing a pt and you are not an expert on the device. Quit inflating your education and expertise.

What type of VAD are we talking about in your hypotensive pt with a vad malfxn. What else is going on? Please understand that you do not know it all. Sometimes there is and will be someone out their with not as extensive an education as you that may be smarter than you and more competent than you at certain aspects of certain issues. Its ok to acknowledge that you dont know at all. Dont be to proud to learn a few things from this person like many of you are. Correct me if I am wrong but :

MD does not stand for = I know everything about every medical issue know to man and I am correct all the time, and am to proud to admit I need to learn and study something more in dept. Just curious thought it stood for Medical Doctor or something, maybe Im wrong.

I can adjust VADS and IABP just as good if not better than any 1st or 2nd year anesthesia, IM resident. Though I def. can not insert one and have no desire to do so I can make balloon adjustments as well as VAD adjustments very well. Many Anesthesiologists run the case and may make VAD and Balloon adjustments in the OR but when the pt comes out and is in the ICU wks to months unless the Anesthesiologist is a critical care intensivist working in the ICU they make little if any device mgmt decisions. Come on now how often do you really make VAD changes, dont inflate yourself. At any facility that I have worked at though the Anesthesia MD may make VAD changes in the OR we all know it's either the surgery of TP cardio or VAd program coordinators that adjust the VAD most of the time

I have become quit an expert on the Debakey Medtech axial flow vad and will put my knowledge and experience to any resident. Im pretty competent managing hearmate I, thoratec, biomedicus and abiomed as well. I have studied probrably the same literature you have. I have managed many many VAD pt's, though not in OR. MOst of the time they crump post-op anyways and reg anesthesia is no where near unless they are bringing the pt back and still it is doubtful that anesthesia is going to be making any drastic VAD setting changes. Intra-op you have way more experience than I, but post op i can trouble shoot VAD related issues as well as many anesthesia residents. Anesthesia has little hands on with vads if any intra op in my experience, and when so they always collaborate with surgery or perfussion before pressing buttons, increasing flows or RPMS, switching drives or even manually pumping and changing filters if needed in emergencies.

Im my experience most anesthesia residents have no clue when It comes to the VAD. They may have a general understanding of how it works but they have no clue how to trouble shoot alarms, DisConnect pt and manually pump if needed, assess bladder filling to assess volume status, do flash tests to assess filling ect. Most of the time when receiving a pt from OR the balloon timing is totally off and needs adjustments anyway.

Again I understand that different facilities may have different services handling these issues so you may been the VAD GOD who knows. But most VAD pt's crump post-op and RN's manage VADS very well. Most VAD coordinators at facilities are RN's as well. I would rather the VAD coordinator RN make Vad changes sometimes rather than any MD. When your at the bedside 12hrs a day 4 x a week with a VAD or balloon pt you get to know that pt and his device very well and are able to recognize subtle changes either in the pt or device itself. Its all about experience man, either you have it, you want it or you are trying to get it. Your medical knowledge makes no difference when you are managing a pt and you are not an expert on the device. Quit inflating your education and expertise.

What type of VAD are we talking about in your hypotensive pt with a vad malfxn. What else is going on? Please understand that you do not know it all. Sometimes there is and will be someone out their with not as extensive an education as you that may be smarter than you and more competent than you at certain aspects of certain issues. Its ok to acknowledge that you dont know at all. Dont be to proud to learn a few things from this person like many of you are. Correct me if I am wrong but :

MD does not stand for = I know everything about every medical issue know to man and I am correct all the time, and am to proud to admit I need to learn and study something more in dept. Just curious thought it stood for Medical Doctor or something, maybe Im wrong.

OK, the bashers are back, I've been sitting in a clandestine corner, but I'm now locked and loaded.

Nitecap, what the f-u-c-k is your objective here? I'm not gonna bore you with my crudentials, nor do I feel the need to post same.

That being said, why do you post your "crudentials"? What is the objective? Do you recall our last interaction? I'm ready to return to that.

Your "skills" bore me. How would you like it if I posted all my "skills" on a CRNA/RN forum board? What would that accomplish? Why would I be at a CRNA/RN forum boasting my "skills", other than with malicious intent?

I do not understand why bashers come to an MD forum and post bashing posts.

Arent there women's clubs? Men's club's? Hunting clubs? Fishing clubs? Can't med-students/residents/practicing anesthesiologists have their own forum, rightly named the STUDENT DOCTOR NETWORK?

JWK is a seasoned professional. Why doesnt he post offensive, malicious posts? Why doesnt Trinity, a CRNA in my previous group, post offensive posts? Is there a degree of professionalism they have that you have missed?

Like I said in our last long interaction, what is your objective here???? Why are you here???

I can adjust VADS and IABP just as good if not better than any 1st or 2nd year anesthesia, IM resident.

I have become quit an expert on the Debakey Medtech axial flow vad and will put my knowledge and experience to any resident.

I have managed many many VAD pt's,

post op i can trouble shoot VAD related issues as well as many anesthesia residents.

Anesthesia has little hands on with vads if any intra op in my experience, and when so they always collaborate with surgery or perfussion before pressing buttons, increasing flows or RPMS, switching drives or even manually pumping and changing filters if needed in emergencies.

Im my experience most anesthesia residents have no clue when It comes to the VAD.

RN make Vad changes sometimes rather than any MD.

Your medical knowledge makes no difference when you are managing a pt and you are not an expert on the device. Quit inflating your education and expertise.

MD does not stand for = I know everything about every medical issue know to man and I am correct all the time, and am to proud to admit I need to learn and study something more in dept. Just curious thought it stood for Medical Doctor or something, maybe Im wrong.

I deleted the rif-raf from this person's post, but the meat of the post is above.

Read it. If this person isnt a doctor basher, then I'm John Tinker.

Nitecap only posts controversially, and I propose he/she should be banned from SDN.

Well, I have refrained from posting on these topics mostly because it does no good and benefits nobody. The only thing that these posts do is hurt one another and I will give you an example of how it has hurt some of you.
My current employer was entertaining the possibility of hiring CRNA's for coverage as we take on a new location. The posts here by the majority (however, not all ) and especially a few SRNA's/CRNA's have soured my view so much that I and my partners have convinced our employer to stick with the MD only approach. I have worked with some excellent CRNA's in the past and would enjoy working again with them. But I will not be apart of this recent surgence of militant nurses.

Good Luck

wobble wobble shake shake it

People on this forum and constantly talking trash and putting one another down professionally and personally. I question anyones mgmt skills if they do not hire an employee due to here say and especially due to crap and exchanges that take place on this discussion board. Why dont you make a decsion that benefits your practice and your patients. Im sure somewhere out there, there are a ton of CRNA's or AA's that would fit in perfectly to your needs.

Thats like saying in not hiring this guy because he is a republican and I dont like what GW Bush is doing. Hire a person for their qualifications not political views and organizational affiliations. It seems you have been a frequent on this board for sometime. You know the petty crap that goes on here. Sometime I wonder if the posters that are on here 24/7 even practice medicine like they say. If so they must have very low patient loads.


Nitecap, You continue to prove my point. :sleep:

Nitecap= ignore

stuck in OR in last couple of days, return to this post today, and see the post from these CRNA/AAs again...

can we, the unity of medical students, gas residents and practicing anesthesiologists just make one simple request?

"may we keep this forum to qualifying posters (people with adequate education and DEGREES of MD)?"

Graduate Medical Forum > Anesthesiologist>

sorry, we still believe the quality and value of education.

every time we try to make an unifying voice among ourselves, you guys have to jump in and argue about how experienced, and how qualifying you are.

what's your point?

if you are not a physician with MD/DO, you are lost in place.

can you just create your own forum somewhere and vent your frustration somewhere else?

leave us alone,




Nitecap, You continue to prove my point. :sleep:

Nitecap= ignore

Nitecap...

you missed my whole point... again.... i am not really surprised....
so i will write it in capital letters: "RNs don' t make ANY medical decisions whatsoever".... RNs can ONLY make nursing assessments and follow physician prescribed orders. an RN cannot make changes unless there is a written protocol already set up by a PHYSICIAN.

I am glad that you are acquainted with VADs. I would equate that with any ICU nurse who is acquainted with CVVH, or other mechanical device... any RN who uses a device for a patient needs to be inserviced on that device. Don't fool yourself in any way that you are ACTUALLY managing the patient. Because you aren't. In fact, Medicare does not reimburse you for patient management. The hospital pays your salary to provide nursing assessment and nursing care.

I am tired of nurses coming onto this website without anything substantial to contribute - and then passing off their experience in the ICU providing nursing assessment and following physician prescribed protocols as some kind of powerplay.

and your point that yo