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CRNA vs MD

Discussion in 'Anesthesiology' started by TripleDegree, Mar 31, 2004.

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  1. TripleDegree

    TripleDegree Joker Doctor

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    Just spoke to an uncle of mine who's an anesthesiologist, and he was saying that there is a disturbing trend towards states relaxing the laws around CRNAs practicing immediately.

    He expects there to be an imminent drop in MDA salaries. Anyone care to shed more light on this?
  2. InGasWeTrust

    InGasWeTrust Member

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    Enter MacGyver...........
  3. gaslady

    gaslady Senior Member

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    A big reason why there are so many really lucrative jobs out there now is because there aren't enough anesthesia providers in many geographic areas. If the supply improves then salaries will likely come down somewhat but they should still be good. Over the years there have been various predictions about surpluses or shortages in all fields of medicine that have affected things like recruitment and job salaries. Some of these predictions have been true, but many have been completely wrong. It's really important not to make perceived job availability or salary a major factor in your specialty choice because these things will change throughout your career no matter what field you choose. As long as you think you will be able to pay back your loans and live at a reasonable level then salary shouldn't play a major role.
    I do think salary is something to consider if you are thinking about going into a field with low reimbursement and have a lot of loans. Anyone who thinks otherwise is naive. For instance, with $170K+ in student loans just for my education and my husband with $110K in loans we would have had a really hard time if we wanted to live in an area with lower reimbursement if he went into primary care and I decided to stay home with the kids or work part time.
  4. MacGyver

    MacGyver Removed

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    That doenst hurt the states, it hurts MDAs. If your scenario were to come true, it gives states the ammo they need to expand CRNAs scope EVEN MORE. If MDAs leave the state, then the state will allow CRNAs to run their own pain practices and do 100% of what an MDA does. Right now CRNAs can "only" do 90% of what an MDA does.

    What? That doesnt make any sense. Overall costs would only go up if CRNAs work under MDA supervision (which doesnt happen anyways in most states).

    Either way, it still hurts the MDA profession. If CRNAs end up making the same as MDAs (which I dispute) it would destroy MDA residency programs. Nobody is going to choose an MDA residency just to make the same amount with teh same scope of practice as a CRNA.

    If CRNAs make less money than MDAs (which is reality) then it still hurts MDAs because it encourages reimbursement to fall to the lowest common denominator. The market wont tolerate paying MDAs more for performing the same services as a cheaper CRNA.

    Sure, there will always be "CRNA" money in the profession. I guess you have no problem with that.
  5. gaslady

    gaslady Senior Member

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    Given that this whole issue keeps coming up (enough to make many of us want to vomit about the way that certain posters twist and turn the facts) I will take the opportunity to write how important it is that as physicians we support our professional organizations. This includes the AMA as well as our specialty organizations. People who don't join use not getting any direct benefit from the organizations as one explanation. Others say that they dont like the way a paticular organization handled a particular issue. We only have one AMA and although it's not perfect without it we would have no one to look after the rights of physicans to be able to take care of our patients. The same goes for ASA and all other specialty organizations. One thing that some of the other provider organizations have that has allowed them to successfully lobby for increased scope of practice in various states is a strong professional organization with powerful lobbists. The main way they are able to acomplish this is through high membership rates and consistent donations from their members.

    Here's an ASA newsletter article about this that I think is relevent to all fields.

    http://www.asahq.org/Newsletters/2004/02-04/crowsNest02_04.html
  6. Drakensoul

    Drakensoul Senior Member

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    Honestly, even if Anesthesia were to drop to $170,000 - $200,000-ish median salary, I'd still be interested in going into the field. It's a fairly nice lifestyle when you compare to, say, OB/GYN, where you work until you fall apart and are still not making much over $230,000 usually. :shrug:
  7. MacGyver

    MacGyver Removed

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    thats not necessarily so. Only a very few states specifically require MDA supervision/collaboration. IN the other states, there is no evidence that CRNAs get sued a lot more, or that their malpractice insurance costs are a lot higher.
  8. Skip Intro

    Skip Intro Registered User

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    Again, by either obviously ignoring or not comprehending what I said, you missed the point... yet again.

    In the states that choose to enact the federal HCFA loophole, there will be no co-liability for any physician who gets sued during a bad outcome because they will not be legally - in any way, shape, or form - liable for the anesthesia care in court. The AANA currently argues that this is already the case, but it's not.

    If a nurse anesthetist screws-up in such a scenario, he/she will not have required a physician sign-off approving his/her work. IN such instances, the physician who requested the anesthesia (be it surgeon, obstetrician, etc.) will be able to say, "I have no responsibility for that part of the procedure." As it now stands in most states, - except the few places where there have been exemptions passed by state Governors - they are currently legally responsible (at least in part) of the CRNA's care despite what the AANA is trying to make the public believe. Remember, we already agreed that this is a nursing specialty, not a medical one (although the AANA is trying to blur that line).

    The result is that the CRNA will not "share" liability with the what-would-have-previously-been supervising physician. The old way, the "supervising" physician could be named in a lawsuit as the co-responsible party. They still technically could, but a judge will like remove them from a civil case (as happens often now in similar circumstances) if they are not legally responsible for that part of the care and the error involves only the anesthesia part of the procedure. This is not the case when they were required to be the supervising physician, and is the basis for why they (the treating physicians) co-lobbied to have this law enacted. It selfishly benefits them by removing liability and placing it solely on the shoulders of the nurse anethetist.

    You'll see. In instances where this exemption is granted, their malpractice premiums will go up. I promise you.

    -Skip
  9. juddson

    juddson 3K Member

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    Skip,

    I'm afraid that I don't understand what you are saying here. Help me to understand the legal fraimwork of CRNA, MDA and Surgeon liability AS IT CURRENTLY exists in your state (we'll just choose your state only because it serves as a convenient vehicle for the discussion).

    I'll lead you so as I don't get lost:

    1. In your state, are CRNA's permitted to practice without MDA supervision or direction?

    2. If they ARE allowed to practice without MDA supervision or direction, must they be supervised or directed by the the surgeon?

    3. In either case, who typically "employs" a CRNA in your state? Or may they be self-employed?

    4. Irrespective of "employment", who is responsible for "choosing" them to be the anesthetic provider? That is, by what mechanism are they "assigned", "scheduled", etc., to provide anesthetic. Consider two scenarios: The first is a hospital trauma OR, the second a suburban outpatient surgery center.

    5. How are CRNA's in your state currently compensated?

    Thanks
    Judd
  10. apma77

    apma77 Senior Member

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    this same freakin topic has been ranted 4000000000 times on this forum. please stop the torture!
  11. Skip Intro

    Skip Intro Registered User

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    Well, I'm a legal resident of Texas, but I'm going to school in New York. Still, I wouldn't limit it to my experiences or my states. Let's use a hypothetical taking a recent issue raised on this thread and one of the HCFA exceptions, let's say Colorado, for the sake of argument.

    According to the exception in Colorado, a CRNA could administer anesthesia without the previous legal requirement of a "supervising" physician's countersignature. This would mean that the CRNA is, de facto, operating on his/her own without 'supervision' or 'direction.'

    Technically, in the scenario I present, they are not. As the law previously stood, they would have been. But, as was successfully lobbied, many of the "supervising" physicians had little or no training in the administration of anesthesia and felt uncomfortable taking on the burden - and legal ramifications - of "supervising physician" because of this. As a result (as happened in Colorado), many such surgeons (or podiatrists, or obstetricians, etc.) would send their higher-risk patients to Denver or larger cities in Colorado where an MDA (or other surgeon, etc.) was willing to take the legal burden of "supervising physician." This is the paramount reason why the HCFA rule was enacted - so these small, community hospitals would not lose such patients to bigger cities that had, according to the law, more adequate facilities.

    CRNAs have historically been members of MDA practice groups. They can, I supposed, be 'free-lance' or form their own practice group if they have a working relationship with a hospital, a particular MDA group, or a surgeon who is willing to take the responsibility of the "supervising" physician and/or indemnify their work. With the new HCFA ruling in the states where the exemption is approved, this is no longer an issue because there is no need for the "supervision" level by a physician.

    Practice groups make contracts with hospitals, surgical practice groups, HMOs (etc.) to provide anesthetic services. If there are surgeries at a hospital that have a contract with a particular anesthesiology group, then that group - and all of that groups employees - are authorized to provide services under that contract. Because historically CRNAs have worked for MDA run practice groups and because the law previously always required supervision, they were marginalized. This means, they were often hired by such a group, given a salary, and only a portion of what service they provided and was billed for was actually given to them. It doesn't matter if it is a hospital or a surgical outpatient center. The contract is to provide the service. The CRNA got a portion of those contract fees as a salary. Often, the amount that the practice group bills the hospital/surgicenter and/or Medicare is substantially higher than the CRNA actually gets paid. It would be no different than if a 1st year MDA took a contract job, for salary, at a practice group and received only a portion of his/her actual billed services in return. Do you follow? The difference is that an MDA does not, by law, have to be supervised (and all of the legal ramifications that go with that) because of the legal status of their license, all of which is regulated by the HCFA, state medical licensing boards, etc.

    Again, I think the answer is above. If there was a private practice group consisting solely of CRNAs that had a contract with a particular group and did not need to be supervised, they would receive 100% of what they billed. They would not have to pay a fee or share the fee they collect with any supervising physician. In the case where the CRNA's work is supervised, the supervising physician collects a portion of the total fee.

    Per Medicare, for example, a physician can collect 50% of the fee of a CRNA for up to four cases at a time. Therefore, if a particular charge is $100 for a case, the CRNA working on the case only gets $50 of what's actually billed and the MDA gets $200 because he/she is supervising four cases at the same time. In other words, with the new ruling in those states that allow the exemption, CRNAs will make twice what they used to for the same caseload whereas MDAs will make 1/4 what they used to.

    Does that make sense?

    -Skip
  12. Leukocyte

    Leukocyte Senior Member

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    when Money talks, BullS**T (=CRNA) walks. :mad:
  13. Fabio

    Fabio Senior Member

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  14. Fabio

    Fabio Senior Member

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    I don't belong in this forum, I'm going into peds, but . . .

    Incidentally, CRNAs are making more than I will as a physician in pediatrics. I have loans to pay back and will not be in a comfortable position for quite some time. I did not have a positive experience at all with the CRNAs I worked with during my 2 anesthesiology rotations . . . and they seemed to be enthusiastic about the amount of independence they would be gaining in the near future.

    I don't know, I guess I just believe in being fair, and you should get out of something what you put into it. 20+ years of rigorous training should come with some rewards, right? (Aside from that great feeling you get from really connecting with and helping your patients!)
  15. apma77

    apma77 Senior Member

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    ok let me restate this...OUR PREDECESSORS SOLD PART OF OUR PROFESSION BECAUSE OF THEIR GREED..THERE IS NOTHING WE CAN DO NOW OTHER THAN TO STOP MORE FROM BEING TAKEN AWAY!

    CRNAs are here to stay...deal with it!
  16. Skip Intro

    Skip Intro Registered User

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    There's the rub. There's no such thing as "just a taste" of freedom.
  17. MacGyver

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    The folly of the MDA organizations is they had no national scope of how to fight against CRNAs. Instead they waited for a few states to change the rules and ONLY THEN got in the fight.

    Thats an incredibly naive strategy. States look to each other regarding trends and precendents that are set. After the first few states change the rules, the CRNA lobby in other states yell "hey, look at the other states, they are doing this" and often thats enough to get them over the hump and expand their scope.

    MDAs and docs as a whole need to be concerned about ALL STATES, not just their little corner of the country. Their failure to do so thusfar has cost all of us greatly.
  18. Skip Intro

    Skip Intro Registered User

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    Well, this is not actually how it happened. The HCFA at the federal level, pursuaded by the AANA lobby, actually changed the law. I posted on this already. The ASA fought it all the way. They are suing in certain states to have the law reversed. They will not likely win.

    Yes, this happens. I agree.

    This is why, as one other poster put it, MDAs, residents, and students in the field or going into the field should join the ASA to protect what's ultimately not only in their best interests, but the patients' as well.

    -Skip
  19. MacGyver

    MacGyver Removed

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    Yeah, but the HCFA action is a very recent development. There were smaller battles going on in states for years prior to this. The HCFA decision didnt come out of a vaccuum. The prevailing state practices and precedents certainly worked to push the opt out provision along.

    You have to be pre-emptive and squash all these things before state legislatures jump on board. Once states change their regulations, the MDs have already lost ground and instead have to focus on damage control.

    Far too many doctors are short-sighted. The prevailing attitude (as witnessed in these forums) is a "it doesnt affect me, we make plenty of $$$" mantra. That may be true in the short term, but by having such a myopic view almost GUARANTEES that others will encroach on the field.

    Everybody wants what MDAs (and docs in general) have. They are going to do whatever they can to achieve similar status by taking shortcuts.
  20. Skip Intro

    Skip Intro Registered User

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    You know, I guess I can't really argue against that. I'd have to agree. This is ultimately all about money.

    -Skip
  21. Tenesma

    Tenesma Senior Member

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    I finally throw in my view of things:

    while I appreciate the fervor of some of the posters - it looks like you all have it wrong - and there is a serious misunderstanding both of the situation and of the issues....

    It is not uncommon for this to be a BIG topic of discussion for pre-meds, medical students and residents early in their training... they hear all of these things about CRNAs, and the automatic response is to become defensive.

    I hate to say this, but so far MacGyver actually has a good sense of what is going on with mid-level practitioners - and their possible effects on medicine and reimbursement as a whole.

    So here are a few things to clear up any issues

    1) CRNAs can practice independently of Anesthesiologists in ALL states ---- they can practice with a "physician" supervising in about 22 states, and in 33 states they can practice without any "physician" supervision at all.... and that "physician" supervision is primarily designed for them to be able to provide medications that they can't independently prescribe in those states....

    ---> So, in effect.... CRNAs can and do practice independently of physician supervision in most states. Don't confuse this with the "opt-out" rulings that have nothing to do with medical supervision, and are only designed to answer the question regarding Medicare Reimbursement.... one is a medical-legal issue the other is a billing issue

    2) CRNAs provide great anesthesia services.... while I find the AANA's statement that they provide 65% of anesthetics to be misleading (cause in reality they only provide "independent" anesthesia in 30-35% of anesthetics around the country - based on Medicare Data)... but still, they provide great services - especially to rural areas, as well as to the armed forces where they outnumber MDAs by 50 to 1.

    3) the argument of CRNA being equivalent to MDAs is an old issue - and most senior CRNAs (not the Student CRNAs or fresh out of school CRNAs who still don't have a clue) and most MDAs know that there is no equivalency. The act of administering anesthesia during a case can be done by both - and there is no data so far to show that a difference in outcomes (despite weak attempts on both sides). The act of administering anesthesia is based on a good understanding of physiology and pharmacology, and a lot of clinical experience... HECK, some of the best senior anesthesiologists I have worked with ONLY have a DDS degree and did a 2 year residency in the 60s.... but they have the clinical experience that would make your head spin.... So in the OR, we are highly trained technicians.... Just like anybody can be trained to do surgery (I know a Cardiac Surgery PA who opens the chest, takes down the LIMA, prepares the saphenous vein, and then assists with coronary anastomosis, then closes the chest --- that is a lot of stuff, considering that in academic programs ONLY the cardiac surgery fellow is ALLOWED to do that).... What makes a Surgeon a Surgeon isn't the operation, but knowing when to operate, knowing how to manage a patient pre-operatively, knowing how to manage complications post-operatively.... What makes a Surgeon a skilled Technician is exhaustive hands-on experience.... A similar analogy can be made as far as MDAs go, we are able to provide true peri-operative medicine - we can provide cardiac or medical clearance for a patient without requiring the surgeons to obtain extra consults for that patient - we play an extended role in the ICU, pain cliinic, pre-op. assessment clinic, PACU etc... In some areas and at some hospitals these things play a significant role and hence the continued demand for MDAs... In fact, if you look at the "opt-out" states where technically CRNAs can practice independently and bill medicare independently - MDAs still get great jobs and great pay for their added value to the hospital services and some of the cost savings they provide.

    My prediction for the future: CRNAs will gain the right to bill Medicare independently in almost all states, they will form more and more of their own groups - heck they might even own the local surgi-center..... As anesthesia becomes safer and safer by the day, MDAs will become more and more Peri-operative physicians with further expansion of their skills into the ICU world... Especially with the Leapfrog studies pushing for dedicated intensivists in ICUs there will be a greater demand, and I wouldn't be surprised if over time ICU care will have better reimbursement than OR reimbursement.

    So for those who say that we sold out the field.... I think there is some fallacy there. When no MDA was willing to work in rural Kansas, what are the surgeons or hospitals supposed to do? close their ORs?... the evolution of the CRNA was unavoidable... demand dictates care to some extent: in rural areas, FPs do c-sections, deliver babies and do appendectomies - they even run their own ICUS!!!!! in many rural areas, NPs and PAs are the only health care provider within 50 miles!!!

    Yes, our salaries aren't the same compared to the 80s --- but that has to do with our weakness as effective negotiators/lobbyists with insurance companies/hospitals... A surgeon will get 1200-1400 dollars for a CABG and 30 days of post-op care (and that includes a possible take-back, opening the chest in the ICU at 3 am, etc...).... which is a HUGE cut from what they got in the early 80s (8-12,000 then)... Whereas Hospitals can still charge 60-90 dollars PER MINUTE for OR time - the hospital association lobbying group is HUGE and has not let the government/insurance companies bully them into lower reimbursement...

    so for those who are going into anesthesia: it is a great field, with a lot of intellectual challenges, a lot of critical care, and very rewarding.... and once you are closer to being done with residency or actually practicing (like me or brachial plexus), then you will see what the difference is between an MDA and a CRNA.
  22. UTSouthwestern

    UTSouthwestern 1K Member Moderator Emeritus

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    An excellent reply Tenesma. Key points I would keep in mind are that we as anesthsiologists are not going to be extinct or driven out of the market by CRNA's.

    As previously pointed out, even in the opt out states like Colorado, there are still lucrative positions available (I am considering a position in Boulder - $250-350K).

    Mid level practitioners are present in all areas of medicine - We have the most because our field gives them the opportunity to make the most money they can.

    Emphasize obtaining a COMPLETE education during your residency (i.e. you may not like ICU rotations, but they will provide you with a skill set and knowledge base that enhances both your intraoperative and perioperative care).

    DONATE TO OUR STATE AND NATIONAL ORGANIZATIONS. You will make a lot of money but you could be making more and our legislative representatives have to have the resources to continue to push our agendas.
  23. juddson

    juddson 3K Member

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    Wait a minute. These two paragraphs seems inconsistent to me. The first all but admits that in the long term MDA will "expand" their scope of practice as peri-operative physicians into the ICU as more and more CRNA's take over the practice of anesthetic administration. It seems to me that the greater demand by ICU's for these MDA is not necessarily a bad thing, but it IS the result of MDA's being pushed out of the OR by CRNA's. What you are saying, in effect, is that CRNA competition will (perhaps will very soon) necessitate a sort of "re-training" (or at aleast a sort of "re-focussing") of MDA's away from the OR and into the ICU. I made this very same point several threads ago. If CRNA's can push gas in the OR, it suggests clearly to me that MDA's are over-trained for this sort of thing, and that greater specialization (or expansion into adjacent and subjacent areas) will become necessary for them. You all but admit as much as this, no?

    Which makes the first sentence of the next quoted paragraph all the more perplexing. The reality is that MDA's HAVE (by your own admission) ceded (sp) the "bread and butter" of gas administration in the OR to CRNA's (perhaps by necessisty or otherwise, as you say) and in the future will need to refocus as peri-operative physicians. I'm not saying being an intensivist is a bad thing (maybe it's a great thing) but it DOES represent a shift for the typical MDA (even though they are the best physiologists by training in the hospital anyway).

    BTW, what is the other route to a peri-operative practice (ICU, etc.). Is it IM with a critical care fellowship? When does THAT war begin?

    My head is spinning.
    Judd
  24. juddson

    juddson 3K Member

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    BTW, I was just having a look at Gaswork.com and noticed that some groups have CRNAs and some simply do not.

    Is it safe to assume that those groups which do NOT emply CRNA's probably work in areas where CRNA practice simply is not that prevelant?

    Judd
  25. MacGyver

    MacGyver Removed

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    Tenesma,

    The essential theme of your post is that MDAs are getting "pushed" to the specialty extremes of gas and into other areas by CRNAs. Thats not a good thing, thats a bad thing.

    If CRNAs can push MDAs in that fashion, who's to say they wont push even further? What exactly iin the past history of CRNAs suggests that once they get to a certain point, that they will be satisfied to "draw the line" so to speak and seek no further scope of practice enhancements? You have to admit that for them to make such a decision would be UNPRECEDENTED, given their well-known past history of activism.

    MDAs can do pain fellowships and other stuff, but that represents a very small fraction of what MDAs at large do. To cede "bread and butter" stuff to CRNAs with the idea that MDAs can still do subspecialties is shortsighted and a recipe for disaster long term.

    Sure, it might not afftect the MDAs currently in residency or practice. But what happens years from now when ALL MDAs have to seek out subspecialty fellowships in pain just to carve a niche for themselves separate from CRNAs? Thats NOT a good sign.
  26. Skip Intro

    Skip Intro Registered User

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    Tenesma,

    Thanks for your comments, but I have some comments to your comments...

    Check me if I'm wrong, but isn't that 55 states? Last time I checked, there were only 50 states and one U.S. Commonwealth (PR).

    :confused:

    But, check me if I'm wrong (again), but is the medical-legal issue really paramount over the billing issue, or vice versa, in this instance? Aren't the two really conjoined? The billing issue segues into the medical-legal. And, the whole reason for this is that there was previously mandatory supervision regulations by the HCFA for reimbursement. By sheer deduction, this automatically brings the "supervising" physician "into the mix" liability wise, and this was the big reason why these rural non-MDA physicians supported the AANA in pushing this through the HCFA.

    I would have to disagree with this statment, unless you completely discount Silber. Do you?

    If this is indeed true and allowed to happen, I would then have to take an unfavorable position and agree with MacGyver with a reasonable conclusion that CRNAs are then pushing MDAs away from passing gas. I recognize that this may be inevitable in some people's minds and, indeed, okay. But, I'm not yet convinced this is the best thing for Anesthesia or the patient.

    Again, a false commodity issue. But, the end does not always, IMHO, justify the means. And, with the outcome of what the true impact on the Anesthesiology profession as yet to be determined is, I'm not sure that by the time I finish MY residency what you're saying now will still be true. Of course, I wouldn't do it anyway solely for the money. I find the field fascinating and I'm developing a burgeoning interest in pursuing it, fortunately not dissuaded by anything I've read so far.

    -Skip
  27. racer

    racer New Member

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    "What will convince me that I'm wrong? If a CRNA specializing in pain management is allowed to administer blocks or prescribe medications, without physician sign-off, in his or her own clinic. Until then, you are misrepresenting (as the AANA does) the law!"

    Search for Cottage Hospital (pain clinic) in New Hampshire. Make a phone call you will not like what you hear.
  28. jwk

    jwk AA-C ASA-PAC Contributor

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    20+ years? - lets see 4 years med school, 16+ years of residency????

    Let's not count kindergarten and onward as "rigorous training"
  29. antiadriani

    antiadriani Junior Member

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    quit freaking out everyone, I am an srna and will always appreciate having the docs around. we wont bite the hand that feeds us, so long as you dont "sell us out", and lower the bar even further by pushing the AA b.s. I will work my butt off to make you guys a lot of money (yes you can have half of my reimbursement), and still respect your expertise. we have to work together though.

    lets get back to taking care of patients together, and do less backstabbing...i realize there are greedy folks on all sides, I will make a commitment to clean up the messes on my side...you do the same.
  30. jwk

    jwk AA-C ASA-PAC Contributor

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    Fine example of "...do less backstabbing..." and "...taking care of patients together..." You've already sold yourself out to the AANA and you're only a student - what a shame. I'm sure you've never worked with or even met an AA. You're simply regurgitating the propaganda profferred by the AANA or your state association or your "nursing theory" class.

    AA's don't lower the bar - we raise it. Learn FOR YOURSELF what AA's are and what they do. Within the anesthesia care team environment, which all of US are committed to, we do exactly the same things as a CRNA in that same practice. If that practice allows regionals by anesthetists, we do them. If they allow central lines, we do them. If they allow anesthetists to do open hearts and neuro and neonates, we do them. The ONLY real difference between an AA and CRNA is independent practice, and that is by design, not from lack of ability. Oh, that and we don't foolishly consider ourselves the equal of an MDA, as many CRNA's in this country do currently.

    Obviously you don't know that AA's had master's degrees 30 years ago when that wasn't even on the horizon for almost all CRNA programs. Obviously you don't know that there are literally thousands of CRNA's out there with NO degree of any kind, just a nursing diploma and an anesthesia certificate from a hospital program.

    Fortunately for us AA's, some people do get the facts before making a decision. The Florida Legislature did in April. And as of about 10 days ago, that also includes the Department of Defense who now INCLUDES AA's as a qualified provider to TriCare patients. Oops - didn't know that, did you?

    Your attitude needs a huge adjustment. Your "I will work my butt off to make you guys a lot of money..." philosophy won't play well at any of your interviews once you finish anesthesia school and start looking for a job.
  31. racer

    racer New Member

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    AA's don't lower the bar - we raise it. Learn FOR YOURSELF what AA's are and what they do. Within the anesthesia care team environment, which all of US are committed to, we do exactly the same things as a CRNA in that same practice. If that practice allows regionals by anesthetists, we do them. If they allow central lines, we do them. If they allow anesthetists to do open hearts and neuro and neonates, we do them. The ONLY real difference between an AA and CRNA is independent practice, and that is by design, not from lack of ability. Oh, that and we don't foolishly consider ourselves the equal of an MDA, as many CRNA's in this country do currently.

    Obviously you don't know that AA's had master's degrees 30 years ago when that wasn't even on the horizon for almost all CRNA programs. Obviously you don't know that there are literally thousands of CRNA's out there with NO degree of any kind, just a nursing diploma and an anesthesia certificate from a hospital program.

    Fortunately for us AA's, some people do get the facts before making a decision. The Florida Legislature did in April. And as of about 10 days ago, that also includes the Department of Defense who now INCLUDES AA's as a qualified provider to TriCare patients. Oops - didn't know that, did you?

    Your attitude needs a huge adjustment. Your "I will work my butt off to make you guys a lot of money..." philosophy won't play well at any of your interviews once you finish anesthesia school and start looking for a job.



    That was all a joke right?
  32. jwk

    jwk AA-C ASA-PAC Contributor

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    What part of this was funny to you?
  33. G0S2

    G0S2 SDN Angel

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    I asked my father, an anesthesiologist, what he thought about the CRNA vs. MD debate. He said that there is a good relationship between the two and that CRNA's rarely have the level of expertise as a MD. Furthermore, he said that since patients seem to be "sicker" in the ICU, when things become complex, the CRNA is happy to see an anesthesiologist enter the room. Medical students interested in a career in anesthesiology need not fret. My father will start off in the OR during induction and will then let a CRNA take over if things are kosher. He will come back in to wake the patient. For more complicated cases, my father is in the OR the entire time.
  34. jwk

    jwk AA-C ASA-PAC Contributor

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    Interesting to have "dad's" perspective. No offense, but that's a somewhat simplistic idea of the relationship and what actually goes on, plus if he is only there for induction and emergence, he hasn't met all the TEFRA requirements for Medicare reimbursement. The MD's tend to have a different viewpoint of the relationship than the CRNA's do, as you'll find out if you search through some of these MD/CRNA threads. Oh, BTW, I'm not a CRNA.
  35. Gator05

    Gator05 Resident

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    JWK, I'd be willing to wager that most of the people arguing for the absolute independence of CRNA's are not, in fact, CRNA's themselves. We've been through this before; the real world is different from SDN, with more maturity usually (not always) the norm. With maturity comes realization of limits.

    GOS2, I think your dad is right on. There will always be a need for competent, well-trained anesthesiologists, because there will always be a need for someone to watch over critically ill patients who need to go to the OR.
  36. bestiller

    bestiller Member

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    How was vacation JW? It's interesting that you mention TEFRA REGS. This isn't a "flaming AA" either. The reason AAs have had virtually no effect on the CRNA market in GA, and will continue to have little effect in other states, has to do w/ those pain in the ass TEFRA REGS. for reimbursement. When working w/ a CRNA the MDA can bill for the case as "non-medically directed", which is huge, when you factor in time savings for the MDA & the almighty $. When working w/ AAs the MDA must adhere to the TEFRA REGS. and bill the case as "medically directed". With the CRNA the MDA has the "more money$ less work" option. The politics may be the main issue for most of the residents on this board at this time but when they enter private practice $ money will become a huge factor. :)
  37. antiadriani

    antiadriani Junior Member

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    alright...alright...so I need an attitude adjustment...see bestillers post about TEFRA...unfortunately there is a lot of truth about that, that is not what drives my motivation in this debate...it is the fact that the ASA sees the AA as the "functional equivalent" of the CRNA. If that is the truth, why then should you need to be "supervised"? Is it by "design"?

    either we should all work together to meet TEFRA regs, or "redesign" them so you too can make your own decisions when it comes to YOUR patient.

    make all the remarks you want about "nursing theory" but one thing that we bring to the table from the nursing perspective is that we are accountable for the patients we care for, whether it means collaborating with the MDA experts, or protecting them from poor decisions....in the OR, and on the political front.

    I am sure you would feel undermined if you were in the rural setting, and a psychiatrist without board certification in anesthesia was "supervising" your practice.

    the reason I think the "bar" is getting lowered is the true motivations for the push on the AA issues by the ASA. it is not about providing more anesthesia providers for the job market, it is about control. the doctors (and rightly so) are hot about crna's being realists:

    "The resultant need to constantly battle the nurses? ?trade union? has been a major albatross for our profession. And for many of us, the final straw was the need for ASA to expend an enormous amount of its scarce resources in response to the recent Centers for Medicare & Medicaid Services proposal to eliminate physician supervision of nurse anesthetists in Medicare/Medicaid-supported facilities."http://www.asahq.org/Newsletters/2003/03_03/mackey.html

    ...the federal government (including the DoD and Tricare...congrats), sees that the old model of reimbursement is not working...the AANA has risen to the challenge, and this ticks off people who want control of the profession...it is not so much the money.

    enter the AA model of practice (which I stress is not a bad model). complete control of your profession (i.e. billing for all the decisions you make as a professional), while meeting the needs of the public.

    what happens when your profession realizes this, and starts claiming their own independence and accountability? uh-oh. maybe we should start a new provider...the practical anesthetist?

    messy isnt it?
  38. jwk

    jwk AA-C ASA-PAC Contributor

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    You act like AA's are something brand new, dreamed up in the last three years by the ASA. Our first classes graduated in the early 70's. It has ALWAYS been the design of OUR profession that we work WITH an anesthesiologist, just as a PA works with their sponsoring physicians. Why it that such a difficult concept? That doesn't mean AA's or PA's are inferior in some way. It just means we're different.

    I don't deny that the ASA has found our group more attractive than CRNA's in the last several years. You think it's about control - we think it's about safety. I've always worked in an anesthesia care team environment, whether it was actually called that or not. It's the safest system for patients. We can dance around the "supervision vs medical direction" arguments all you want, and I won't pretend to know all the nuances of CMS and private insurance billing miscellania. I do know that my practice fulfills TEFRA requirements to the letter of the law, and we all still have a very comfortable living, MD's and anesthetists alike. I don't believe for a second that CRNA salaries are depressed in areas that have AA's. No one has ever shown that to be true.

    I'm not sure where you think that we're not "accountable for the patients we care for" just because we're not nurses. That statement is nonsense. We're responsible for our own actions, just like any other medical professional. If there's a mistake made, we get sued just like a CRNA does. Yes, the MD gets sued as well, but in an ACT practice, a CRNA would be sued along with the MD also.

    We have not and are not seeking independent practice. And whether you believe it or not, the ASA does not have "complete control" of our profession. Unlike CRNA's, who are trained, tested, certified, and recertified, all by the AANA and it's affiliated organizations, our graduates are trained in programs that fulfill certification requirements of the AMA and CAAHEP, and testing is done independently through the NBME. Certification is done by through the NCCAA, just as the NCCPA certifies PA's. Both are independent organizations.

    What AA's really wish would happen is that we be accepted for the competent providers that we have already proven ourselves to be for more than 30 years. We're not trying to steal jobs from CRNA's or push them out of the market. We don't seek to limit CRNA's from practicing independently. We don't seek laws to ban CRNA's from practicing in a state by making misrepresentations to state legislatures. We don't seek to dissuade employers from hiring CRNA's. We're well educated, competent professionals who want to practice in our chosen field, no more, no less. All the arguments leveled at us about having inferior training and no experience is simply a smokescreen because CRNA's are afraid of the competition. Let those anesthesiologists or hospitals who want to hire AA's as part of their practice be able to hire them. Let those anesthesiologists or hospitals who want to hire CRNA's be able to hire them. Let the groups who are wanting and willing to hire a competent ANESTHETIST of either type be able to hire them. Let the free market system work. There's such a huge shortage of anesthesia providers of all types, and there's room at the table for all of us.
  39. bestiller

    bestiller Member

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    JW, your practice (AA) MUST follow TEFRA Regs. to the letter of the law, that means that your MDA must be present in the OR for inductions and extubations. Is he/she present? :confused: If the answer is "no" then fraud is being committed, and it should be reported. :) As I mentioned before the MDAs out there that are making $500-600k/year or more aren't using the ACT approach. They are working in a anesthesia group setting w/ CRNAs and billing "non-medically-directed". I will use the following example: You have an anesthesia group that covers 4 hospitals that run 10 ORs a day. You have CRNA employees that work for you that sign over 50-60% of their reimbursement. You send 1 MDA to each hospital w/ 10 CRNAs each day. That MDA is making 50% off of 10 cases legally by billing "non-medically directed", which bypasses the TEFRA Regs, which cannot be done with an AA b/c they are not independent providers. Keep in mind reimbursement is the same whether the case is "supervised" or "non-medically directed". If it were AAs in that example, the scenario would require 3 MDAs b/c TEFRA Regs.(no more than 4 AAs to 1 MDA)which cuts into the profit margine for the group. 50% of 10 beats 50% of 4 any day! This is where the ability of CRNAs to practice independently is literally worth it's weight in gold to the MDA who wants to be a multi-millionaire. This practice structure is the most profitable period! The opt-out issue is a paper tiger and most experienced MDAs and CRNAs know it. You will never get a large medcial center w/ an all MD board to contract anesthesia services to an all CRNA only group. The AANA can opt-out in all 50 states and it is still up to the individual facility.
  40. jwk

    jwk AA-C ASA-PAC Contributor

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    I wouldn't want to be the patient at a hospital with one anesthesiologist for 10 rooms. It's not always just the money - it's about good patient care. I suppose there are places that operate like that, but I'll bet there aren't many. There used to be, but I don't think it's the predominant system any more.

    If you read my last post, I said we follow TEFRA regs to the letter of the law. Yes, an MDA is present for EVERY induction and EVERY emergence, and signs the record while they're in the OR attesting to that fact.
  41. bestiller

    bestiller Member

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    JW, The above scenario is practiced all over The U.S. by the MDAs that The ASA refers to as "apathetic" or "uninvolved" b/c they never bought into the ACT. I wouldn't either if it meant I was going to make $250k(a CRNAs salary in the above example) vs $600K. I have practiced in the kind of group structure mentioned above for years and there have been no "mass killings" or "grave mistakes". As I said before many MDAs see this and it is the AAs Achilles Heel. It's like you can see the light bulb turn on in a new MDA's head when he/she realizes how much more $money they can make by trashing the ACT and going it "unsupervised" w/ 50-60% of the CRNA's billing. :)
  42. antiadriani

    antiadriani Junior Member

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    yep...

    "Anaesthesia was born a slave; and she has ever remained the faithful handmaid of her master Surgery" the foremost British anesthetist Dr. Frederic W. Hewitt 1896.

    Kinda off to a bad start dont you think? That attitude made it easy for us to participate in a golden opportunity since by tradition we have a little humility. Amazing how times have changed, and we all know we have the most important job in the OR.
  43. MacGyver

    MacGyver Removed

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    Your attitude is EXACTLY the reason why CRNAs have achieved such substantial market share to begin with. Far too many MDAs have your attitude of "I want to get rich quick, sell out my profession, and cash out and retire before it goes to hell"

    How long do you think CRNAs are goign to be content to work under your thumb? How long will it be before they realize that THEY DONT NEED MDAS and can do whatever the hell they want, make the same reimbursement from insurance, and not have to be "supervised" by you at all?
  44. conservative

    conservative Junior Member

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    You're correct, greater CRNA autonomy may not be too far off. CRNAs could make enormous gains as early as next year depending on what occurs in November. With a democrat in the white house, elimination of the Medicare physician supervision requirement for CRNAs could be resurrected. Bill Clinton tried to eliminate the Medicare physician supervision requirement with a sneaky last day in office outgoing executive. However, with a lot of good hard lobbying work it was ultimately overturned.

  45. Gator05

    Gator05 Resident

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    As a 4th year MS, I used to wish the upcoming elections were earlier, to see how the new President would work on the CRNA issue. Then I realized that repeal of the supervision requirement was a question of when, not if. A bit disheartening.

    Had an MDA point something out to me the other day; most of the CRNA's are taught to conduct anesthesia in just a couple of ways, ie propofol/fentanyl, epidural/spinal, etc. He opined their techniques not to be as complex, and not as custom-fit to each particular patient. And the more I study for anesthesiology, the more I realize how much of the advanced training focuses on tailoring techniques to particular cases/patients. I guess P/F works for most of these cases, but I'm beginning to suspect it's not the BEST method for some (most?) patients. Please feel free to correct me if I'm wrong, as I'm heading out past my knowledge-comfort zone.

    Interesting, I'm on NICU now, where >1/2 of the patients are cared for by NNP's. They're VERY good. Could probably act completely independently. I've never once heard an NNP/NNP student say their education was superior to an MD's. I've actually heard the opposite, the appreciation for the decision-making skills developed during medical education.

    While mid-level practitioners are gaining ground everywhere, it seems some of the CRNA's are the most obnoxious and scary of the bunch.
  46. conservative

    conservative Junior Member

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    The few CRNAs I know are of the new breed (mastered prepared); they appear to know the deeper scientific principles fairly well and seem to be taught to function autonomously and competently utilize a variety of techniques and agents. However, the newer breed is the minority and even the newer breed still lacks a medical education and I would worry about them handling the more challenging cases.

  47. florida

    florida Junior Member

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    I 've just started my catagorical anesthesiology residency. And we start of with a month of anesth. Yesterday I followed around an attending and a CRNA student. The SRNA had about 7 months of clinical anesthesia and she was very adament about doing everything and telling me when I was doing things wrong. Whatever, that's fine - I don't think she understands this is my bs month of internship and I could give a shi_. But I got some insight into how limited a CRNA's medical knowledge is when we went to sedate a child for an LP in pediatric oncology. The attending performed the anesthesia in both cases, but filled out the paperwork in the first case. The the attending asked the onc nurse what the diagnosis was and she told us ALL. So, the next case, the SRNA grab's the paperwork to fill out. She calls out "what's the diagnosis". The pediatric oncologist states, "lymphoma". The SRNA confidently replies, "so it's ALL then". At this point the pediatric oncologist snorts and yells, No it's LYMPHOMA!

    And all I could think was for all practical purposes this person would be practicing medicine independently in ~1yr. Sad and frightening.
    Excuse me, I meant to say practicing "nursing" independently. As CRNA's believe anesthesia is the practice of nursing

  48. antiadriani

    antiadriani Junior Member

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    you're absolutely right. damn srna did not know jack. since you could give a shi_, you should probably learn everything there is to know about anesthesia from the pediatric oncologist who obviously understands the practice of medicine. get the chip off your shoulder and stop nurse bashing. of course you will learn this quickly as an intern.
  49. TofuBalls

    TofuBalls Bring the Pain!

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    "Fable"

    The mountain and the squirrel
    Had a quarrel,
    And the former called the latter, "little prig":
    Bun replied,
    You are doubtless very big,
    But all sorts of things and weather
    Must be taken in together
    To make up a year,
    And a sphere.
    And I think it no disgrace
    To occupy my place.
    If I'm not so large as you,
    You are not so small as I,
    And not half so spry:
    I'll not deny you make
    A very pretty squirrel track;
    Talents differ; all is well and wisely put;
    If I cannot carry forests on my back,
    Neither can you crack a nut.

    -Ralph Waldo Emerson

    Instead of constantly worrying about this issue, why not just concentrate on becoming the best and most diverse physician you can be. In the long run this will secure your place in our chosen profession and help to weed out those craven souls who are working daily to run it into the ground. :idea:
  50. NikiVIBES

    NikiVIBES Junior Member

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    I like that little poem Tofu. And well said in the subscript. I'm thinking about going into anesthesia. I think its a fascinating medical field. I also think those who chose or have chosen to go into that field are extremely talented and gifted individuals who genuinely appreciate the beauty and complexity of the human body. Actions will speak for itself whether it be CRNA or Anesthesiologist. I'm just a premed student who work in the OR and I've wittnessed anesthesia delivered by both profession. I have to say that I have seen really good outcomes as well as really horrific ones. The sad thing though, is that the results were reflective of the personalities of each and everyone of them. So back to all the bickering, I honestly think that all anyone can do is be the best they can be and do the best they can do.
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