Louisiana CRNAs want to practice Interventional Pain

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http://www.lsbn.state.la.us/document...enda120705.pdf

http://www.lsbn.state.la.us/document...enda042705.pdf

http://d1724106.u29.globalhosting.co...gChallenge.PDF

http://d1724106.u29.globalhosting.com/news_alerts.html

ASIPP member in Baton Rouge is trying to legally attack this, but it looks like the nursing board is arguing that epidural steroid injection, peripheral nerve blocks and facet injections are within the scope of practice of a CRNA....

another reason to support the ASIPP (as they are our best legislative defenders)

side note: i also encourage everybody to support ISIS for research and science reasons

CRNAs will have an interventional pain fellowship

You'd brought up a topic similar to this almost 2 years ago. Still people turn a blind eye. I find that most time physicians are reactive, unlike CRNAs, PAs, PTs, NPs, Psychologists who are very aggressive in their lobbying for what they want.

Hopefully ASIPP member will have the legal support that it needs.

Fromt the California Society of Anesthesiologists -

"CSA Sues Board of Registered Nursing

On Wednesday, August 31, the CSA filed a lawsuit against the Board of Registered Nursing (BRN) accusing the BRN of adopting "underground regulations" expanding the scope of nurse anesthetists' practice without complying with the Administrative Procedure Act. BRN recently revised a document entitled "Practice of Certified Registered Nurse Anesthetists," which now states that nurse anesthetists can practice without physician supervision. The second new rule, promulgated by the Board for the first time in the same Bulletin, states that nurse anesthetists, as independent practitioners, may practice pain medicine, a recognized subspecialty within medicine, and particularly within anesthesiology.

The suit alleges that both new policies violate established California law, and asks the court to declare that the purported new rules are legally invalid. The CSA also seeks an injunction prohibiting any further use of these expanded practice rules by BRN unless the rules are adopted after public hearings that comply with California's Administrative Procedure Act and survive judicial scrutiny thereafter. The CSA believes that such rules would be unlawful, and beyond BRN's authority. A hearing date will be scheduled soon."

Support your local/national physician's societies!

It is this type of brash, unchecked, uncontrolled activism with state nursing boards de facto creating their own separate medical system through expanded definitions of the scope of practice that will create immense and long lasting hostility from physicians. Although I believe based on experience in teaching and observing CRNAs that their capabilities in low level interventional techniques and diagnostics far exceed that of the family practitioners being trained in interventional techniques by all the major pain organizations, I cannot condone the creation of a separate and unregulated medical system run by nursing boards without input by the governments of the states. I totally agree in this realm, it is time to support the national pain physician political organizations, ie. ASIPP, to curb the abuse of power by the nursing boards nationwide.

CRNA's in Louisiana are pretty much out of control, as evidenced by last year's legislative debacle banning AA's from practicing there, even though AA's couldn't practice there to begin with.

Originally Posted by algosdoc

It is this type of brash, unchecked, uncontrolled activism with state nursing boards de facto creating their own separate medical system through expanded definitions of the scope of practice that will create immense and long lasting hostility from physicians.

It worked for the psychologists in LA, who now have prescriptive authority:http://www.louisianapsychologist.org...ubarticlenbr=6

Who's to say that, without proper training, nurse anesthetists are not able to safely and effectively practice pain management?

Face it, it's all about the benjamins, baby.

Originally Posted by PublicHealth

It worked for the psychologists in LA, who now have prescriptive authority:http://www.louisianapsychologist.org...ubarticlenbr=6

Who's to say that, without proper training, nurse anesthetists are not able to safely and effectively practice pain management?

Face it, it's all about the benjamins, baby.

At some point, patient welfare has to come into play - it's NOT just about $$$. Pain management is a separate 1-2 year fellowship with it's own sub-specialty board - CRNA's will never have that kind of training.

My beef is not that CRNAs want to do pain management...they have been doing so for years. The sea change that has happened is that they want to do it independently AND WITHOUT LIMITS on their scope of practice. The only requirement is that they receive training from someone, anyone, in advanced techniques and presto, they are now practicing advanced pain procedures. Effectively they are setting up a competing medical system under the guise of the nursing boards.

Originally Posted by jwk

Pain management is a separate 1-2 year fellowship with it's own sub-specialty board - CRNA's will never have that kind of training.

But who's to say that CRNAs cannot practice pain management? It's analogous to other non-physician practitioners. PAs do pretty much everything a primary care doc does -- they have 2 years of training, primary care docs have a minimum of 7 years.

Sure, pain docs will always be the "king of the mountain" in pain management, but that does not mean that mid-level providers such as CRNAs cannot be trained to safely and effectively practice in this field.

PAs practice under the direction and supervision of a physician trained in the field. CRNAs have created their own separate medical system in which they can take a couple of courses and now can implant spinal cord stimulators independent of any physician. Perhaps you don't have an issue with that, but the vast majority of pain physicians, including me, do.

Originally Posted by PublicHealth

But who's to say that CRNAs cannot practice pain management? It's analogous to other non-physician practitioners. PAs do pretty much everything a primary care doc does -- they have 2 years of training, primary care docs have a minimum of 7 years.

Sure, pain docs will always be the "king of the mountain" in pain management, but that does not mean that mid-level providers such as CRNAs cannot be trained to safely and effectively practice in this field.

PublicHealth,
CRNA's should only be able to practic pain management under the direct supervision of a pain specialist. God forbid that complications arise during a procedure and the CRNA needs a neurosurgeon. How many neurosurgeons do you think would be willing to back up a CRNA in such an area where malpractice suits are already eminent? Likewise, why would another physician refer to a CRNA over a board certified pain specialist who has undergone far more extensive training? If CRNA's want to practice pain independently then they need to go back to medical school, do an Anesthesia or PM&R residency followed by a pain fellowship. This issue infuriates me and spits in the face of all those who have spent a considerable amount of time, money, and effort obtaining credentials to practice pain medicine judiciously. As the saying goes "If you give them an inch they will take a mile"

Originally Posted by algosdoc

PAs practice under the direction and supervision of a physician trained in the field. CRNAs have created their own separate medical system in which they can take a couple of courses and now can implant spinal cord stimulators independent of any physician. Perhaps you don't have an issue with that, but the vast majority of pain physicians, including me, do.

Procedures is one thing - surgery is another. Implanting a spinal cord stimulator is surgery in anyone's book, and clearly the practice of medicine, not nursing. Interesting that the first picture that loads up on www.AANA.com (at least as of this writing) is a picture of a CRNA doing a pain procedure. Gimme a break.

What hospital or outpatient center in their right mind would allow this? What malpractice insuror in their right mind would allow this?

You're right - mid-level NURSING specialists are trying to create their own "medical" system, claiming they're cheaper and better, some with just a associates degree and a correspondence "nurse practitioner" course.

So the division between the practice of surgery and that of a CRNA is decisively defined? Just like the division between anesthesiology (the practice of medicine) and CRNAs (the practice of nursing)? Yeah right....
Two weeks ago I would have agreed with your position but am overtly alarmed by the recent activism of CRNAs in at least two states. I have always been a supporter of CRNAs doing limited pain procedures (epidural steroids, peripheral nerve blocks, etc) but the wording in the CRNA documents provide for unlimited use of pain procedures. Disc decompressor is a pain procedure and can now be used by CRNAs in those states. Spinal cord stim implantation is limited only by a place to do the implants....a group of CRNAs owning an ASC can do pretty much whatever they please just as can a group of physicians with the same type of ownership. Malpractice, in case you have not noticed, for CRNAs is only a small fraction of that paid by MDs, even if the CRNAs are practicing independently. So the malpractice situation for CRNAs financially is not at all on par with MD rates. Will a malpractice carrier grant CRNAs coverage....it depends. The CRNA malpractice carriers already are cutting the CRNAs a huge break on the price of their product, ostensibly because they are duped concerning risk. So why could not a CRNA simply list "procedures defined by the scope of practice of CRNAs" as a catch-all term on their application for malpractice, and be covered?
The danger from CRNAs setting up their own medical system is imminent.

I think that the real concern is patient safety. The most dangerous situation for any patient in our health care system is at the portal of entry: Specifically, the presentation of a medically-complex undifferentiated complaint.

Pain is medically complex. The differential diagnosis for most painful conditions is broad and includes serious and life threatening conditions. Shouldn't the most comprehensively trained individual be at the portal of entry to that system in order to rule out serious and life threatening diseases? That is where our training as physicians matters the most. Anyone can learn to do an epidural, but learning to recognize benign from malignant disease is simply a matter of time and pattern recognition. You can't do some thing (or a test or get a consult or call for help) if the thought or possiblity doesn't cross your mind.

I'm all for mid-levels assisting physicians and delivering routine follow-up medical care (med refills, simple repeat procedures like pump refills etc) under the supervision of a physician, but to put them on the front-line of patient care without adequate supervision and training is dangerous to patients.

Great,

We're sitting here talking to each other on an obscure forum and they are lobbying to pass laws. Has anyone talked to Lax about this? What is the plan? As docs, if we don't become activists, we become powerless. All this after the fact crap doesn't work. It's time to forge ahead and put a stop to this- or we lose our livelihood.

Originally Posted by lobelsteve

Great,

We're sitting here talking to each other on an obscure forum and they are lobbying to pass laws. Has anyone talked to Lax about this? What is the plan? As docs, if we don't become activists, we become powerless. All this after the fact crap doesn't work. It's time to forge ahead and put a stop to this- or we lose our livelihood.

Have you mailed your check to PA Committee of ASIPP? I am going to do it right now.

Originally Posted by Pain Specialist

Have you mailed your check to PA Committee of ASIPP? I am going to do it right now.

As soon as I can afford I will too!

Originally Posted by Pain Specialist

Have you mailed your check to PA Committee of ASIPP? I am going to do it right now.

The problem is that the medical establishment is so busy fighting for territory amongst each other that they often ignore outlying groups.
It would be a miracle if the AMA and the Amer. Osteopathic Association worked together toward common goals, thus paving the way for the American Society of Anesthesiologists to work in conjunction with the AAPM with respect to pain medicine. If the ASA/AAPM/ASIPP all worked together, who knows what we could accomplish.
It all starts at the top, and I wish that the AMA and AmOsteoAssn could get the ball rolling using their respective specialty associations so we can stop screwing around with these outlying groups.
It's politics, baby, just politics.

Having a nurse do epidurals and interventional procedures is a bad idea. A physician needs to oversee this type of procedure and the physicians need to think about the consequences of a complication at the hands of a nurse. who determines training? who determines credentials? who determines clinical privlidges? it is an interesting idea and i think it could happpen, but as a patient, i wouldn't want a nurse doing this for me.

Hey maybe MacGuyver wasnt so wrong after all??!!!!
I am a med student and I get stuff in the mail all the time from amsa. It is always the same political platforms, support amsa to get medicare/medicaid funding from the govt, help us get healthcare for those less fortunate. Maybe it is time for us to tell us student representatives to let those in their respective organizations know that we as students want initiatives to be targeted at mid levels trying to gain privileges that should be within the realm of the medical community. You are right we wont get anything done here on this forum but if you seriously are concerned as a student or resident maybe you should email the students or residents that you know that are the politically connected people of your class or whatever and let them know how big an issue this is. I know that most people probably dont consider this fight to be highclass (its not as highbrow as fighting for healthcare for the poor) and dont probably want to be associated with it b/c it makes us seem like we are being money hungry, but it is a fight that needs to be fought. It is funny how the crna website shows interventional procedure being done by a nurse and then there is a quote saying "we provide healthcare from the heart". This quote is baseless. So what are they saying, doctors provide healthcare from where....it seems as if they are implying that doctors dont have hearts, whereas crnas do. This type of political rhetoric may have been true before, but not now. CRNAs are the most hypocritical in their greed. They try to hide it with these assertions that they are the only ones who connect with the patient with the closeness of some type of blue collar friendship, whereas the dr is some white collar snob, give me a break, and please dont argue me on this one b/c the implications are there and everyone can readily see it.
I have argued with crnas in the past, and their last line is always "well if you feel that way about a nurse lets see you when you have to work with them everyday, you better treat them right" (well what about treating my profession right, nurses dont seem to worry about having to work with upset students, residents, or attendings by encroaching into their fields), or my favorite from a crna is this "well me and an anesthesia resident were being pimped by an attending, and I knew all the answers and the resident fumbled along".
Now nurses are trying to practice all types of medicine. CRNAs are now trying to get PhD's. They will be called Drs. Why do nurses love to flaunt the initials after their names. I have seen namebadges with Mary Smith Preschool Diploma, Day Care Diploma, Middle School Diploma, GED, RN, BA, BSN, MPH, MS, CPN, LPN, APRN, PhD...............
Being a DO I can see the writing on the wall. We seriously need to band together. DO students are trying to get a joint match, but our higher ups are not going to allow it yet..... I think most DO students realize the absurdity of any types of separations, I for one think that the schools should merge and residency training in osteopathic treatment could be an MD residency for those interested. I think we need to come together and quickly to legally fight these unsafe practices, unless we want third world medicine at first world prices.

Beyonder,

Of course you're right, but when it comes to actually "affecting change" the best course of action is to always, "take the higher ground." If it's only about money, turf, opportunity, power, etc then no one will really listen to you. Lawmkers and policy-makers could care less about turf between MD/DO's and allied health staff. They could care less about professional issues between CRNA's and anesthesiologists---they want to get re-elected next year and they have constituents in their districts who get crappy health care or no health care at all. They could care less about the initials behind a persons name as long as the big campaign donors are happy with their health care at home. They could care less if "the provider" is a MD-DO/CRNA/AA/RN/PA-C or whatever...

However, if you frame these issues as concerns about patient safety, quality, cost-effectiveness health care, access to care, science, and ethics then people who can change things will be interested in listening. More physicians need to be involved in policy and politics, but the sad fact of the matter is that most physicians find this work unappealing. Consider getting some training and experience in health policy type work and keep up your advocacy efforts.

Look at who the allied health groups give money to:

CRNA PAC

Physical Therapy PAC

Psychology PAC

Chiropractic PAC

Only $13K in political contributions separates CRNA's from Anesthesiologists?? That's terrible! I hope that this "new breed" of anesthesiologist that I keep hearing about intends to aggressively restrain the CRNA scope of practice.

I have been fighting this battle for years on this board, constantly being chastised as a "doom and gloom" guy just making stuff up.

Now the rest of you guys finally get it: I WASNT MAKING THIS **** UP, THESE GUYS ARE FOR REAL!

CRNAs are VERY clever. Notice how they frame the argument. They dont argue that CRNAs cost less, they argue that CRNAs doing more procedures means more health care access for everyone.

Notice that they DONT say that CRNAs can practice medicine. If they said that, then thats a de facto admittal that the state medical boards (controlled by MDs) have regulatory power over them. What they DO claim is that interventional pain procedures are the practice of "nursing" and therefore the state nursing board has SOLE AUTHORITY to determine scope of practice.

Thats the key. Change the laws to where state nursing boards no longer have sole authority to set their own scope of practice and maybe this avalance of scope expansions will slow down. As long as the state nursing boards have sole authority to determine their own scope of practice, MDs are screwed.

MDs need to argue that interventional pain mgmt is NOT nursing practice but instead "medical" practice. That way the state medical boards will have sole regulatory authority, instead of these jackass nursing boards going wild

Originally Posted by toughlife

49 states
(all but New Hampshire) require physician supervision of CRNA's.

That is such a bull**** argument.

The fact is, that "supervision" in most states is nothing more than a chart review 6 months AFTER THE SURGERY by the MD. "Supervision" in many states is a total sham, the MD can "supervise" the CRNA while the MD is in a different hospital in a different city!

I'll say this again: MDAs are whoring themselves out to the CRNAs and it is going to screw all of us over. MDAs are the ones agreeing to these SHAM supervision rules and hoping to profit from it.

This was a problem LSIPP first brought to light in Louisiana about a year ago, and was actively opposed by the joint forces of ALL the local medical organizations.

The problem is the alphabet soup of our world of pain. These are STATE organizatons, so they need to be addressed at the state level. But when we divide ourselves by specialty (Anesthesia, PM&R, Neurology, Psychiatry, Orthopaedics, Neurosurgery), or organization (ASIPP, ISIS, SPPM, AAPM, ASA, AAPM, AMA, NASS, ASRA, etc) we divide and conquor, and in no way forward the agenda we clearly all have in common regarding this issue.

The reason Algos speaks in generalities is that he dislikes ASIPP. ASIPP and ISIS can't get along until Drs. Manchikanti and Bogduk learn to play nice together, or until a new generation arises. Meanwhile, while we have our internal turf battles, outside forces like CRNAs and PTs whittle away at our field, and our organizations don’t even know until it is virtually a done deal.

Bottom line - we need to stop sniping internally, and circle the wagons when the field we ALL practice is being attacked by external forces.

Just a clarification: ASIPP is a great organization. It is their leadership's chosen methods and direction with which I have profound disagreement.
PAZ is correct though- regardless of societal loyalties and affiliations, there are certain areas of common interest in which we must come together in order to avoid destruction of our empire by the barbarians at the gates.