AANA Economics

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15 January 2011 02:47
Elizabeth WT


I am a practicing CRNA for 15+ years and think this debate has gone completely crazy. First of all, to the other CRNAs who are salivating at the prospect of running the show by themselves, be careful what you wish for. We do not take call like MDs, our hours are better, and if you actually look at the per hour salary, we are closer to anesthesiologists than you realize. Secondly, I can honestly say I would not be the competent CRNA that I am today were it not for the vigilant supervision and teaching that anesthesiologists have provided me over the years. So many times in my career, the you know what has hit the fan, and the anesthesiologist has come to the rescue and prevented me from looking like an idiot. Sure, I feel confident now and can do many ASA1 and ASA2 cases without much supervision. However, knowing that an anesthesiologist is around the corner to help is something I think is genuinely better for the patient. Let's be honest here. The anesthesiologists did go to medical school and residency, so obviously they are going to have more knowledge and skills than we have. That being said, I do not appreciate the belittling that some physician groups have done towards CRNAs --- we are an essential and valuable part of the anesthesia team and should be treated accordingly. The badgering that is going back and forth is ultimately all about money and should be about patients. Do I think we should be supervised? --- yes. Do I think we should be treated as useless technicians? --- no. We need to increase the dialogue and be respectful for our patients sake.

Elizabeth WT
CRNA
Maryland
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The CRNA job market must be terrible. I read a statistic somewhere about there being only 10,000 CRNAs total in in the 1990s, but now they pt almost 3,000 a year. The SRNA program associated with mine puts out plenty of graduates but I know for a fact they aren't hiring while pretty much any resident graduating has a job waiting.
 
BLADEMDA said:
. Your current Group is employing these "semi-solo" CRNAs for monetary gain. Since CRNAS are expensive and MD (A)s even more so they are cutting corners by allowing CRNAs to function in an Independent manner. .
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Don't i know it? The man who hired me is a detestable sell-out to the field i love. I need to get out as soon as possible; sadly, it would be the perfect job for me if there were no CRNAs - great location, great surgeons, great nursing staff. I'm up for partner in a few month but i'd much rather leave and take a lesser paying job with no partnership than work with "independent" CRNAs anymore.
 
BLADEMDA said:
Since the AANA claims "equivalency" in terms of CRNA=MD (A) the "mixed group" sends a strong message that the claim is true. Hence, "expensive" MD Anesthesiologists should be replaced with Midlevel Anesthesia Nurses wherever possible. In the short run the "mixed group" does save some money to the hospital in terms of stipend but at what long term cost?

If the "mixed group" model were to become the predominant player in our hospital systems newly graduated MD (A)s would be forced to accept lower salaries. This in turn would force the CRNA to accept a lower salary to keep his job or compete for a new one. Finally, the AA would be forced into a major paycut to keep his/her job.

So, who ends up the winner here over the long term? the AANA.
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The idea that any CRNA or even the AANA really cares about the longterm implications of this is crazy. They don't. Each individual cares about themselves and would like to get more independence/power/$$$ in their career. They don't care about 50 years down the road, because it is irrelevant to them and their career.

It's a short sighted attempt at a money grab with the idea that it probably won't kill too many patients. Besides, everyone thinks they are the best anyways. We all know that one CRNA (well, there's more than one) that is always trying to off somebody in the OR and making bad decisions. Guess what? They don't know they are incompetent. They think they are great.

The people that want independent practice the most tend to be the worst providers. The best ones already are independent, essentially. I mean when I'm working with our handful of outstanding CRNAs it's not like I'm changing up what they want to do all the time. They're already doing the right thing 98% of the time. The majority of my time is spent helping the rest avoid doing something bad to somebody.
 
"Mix model systems are existent in primary care, ICU and ERs/urgent cares (i.e. NP's) and OB centers (i.e. midwives). I don't think any of them have crashed their respective fields. I think medical students (and BSN's) will continue to go into anesthesia because it is an engaging and challenging field. Hopefully, we will continue to see a rise in education and research, as well. However, I think an issue of falling reimbursement is looming. With this in mind, I think it will get progressively more difficult for solo practices of any sort to compete and survive in the marketplace. Rather, we will see more groups consolidating (or selling to a management company) to have more bargaining power with insurance groups. Will this be the WalMart effect on anesthesia? I can't say for sure but the landscape is changing fast. "

AnesthesiaMD
​
 
BLADEMDA said:
"Mix model systems are existent in primary care, ICU and ERs/urgent cares (i.e. NP's) and OB centers (i.e. midwives). I don't think any of them have crashed their respective fields. I think medical students (and BSN's) will continue to go into anesthesia because it is an engaging and challenging field. Hopefully, we will continue to see a rise in education and research, as well. However, I think an issue of falling reimbursement is looming. With this in mind, I think it will get progressively more difficult for solo practices of any sort to compete and survive in the marketplace. Rather, we will see more groups consolidating (or selling to a management company) to have more bargaining power with insurance groups. Will this be the WalMart effect on anesthesia? I can't say for sure but the landscape is changing fast. "

AnesthesiaMD
​
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This particular individual is either ignorant or pandering to the Militant Nurse crowd. Let's examine the implications of a "mixed model" system as proposed by the AANA/Militant CRNA and compare it with other mixed models in OB/ER/ICU.

1. AANA claims "equivalency" and as such, its providers should have all the same privileges/rights as their MD (A) counterparts. This means CRNA care from start to finish with no MD(A) involvement reqired or even needed. The Mixed Model in the O.R. is EXACTLY this equivalency as it essentially involves NO MD Anesthesia involvement. Is this what E.R. Doctors face with their PAs? Does a Nurse Midwife have the "right" to do a C section when things turn ugly? Does an ER PA have the "right" to do ALL the same procedures as an ER attending?

2. The Mixed model in the ICU, ER and even OB still leaves the Physician in charge of making the critical decisions and being involved with the most difficult procedures. We have such a "Mixed Model" already in Anesthesia and it is called the "Anesthesia Care Team" approach. This doesn't mean every case must be "micromanaged" by the Attending or even that the CRNA can't push drugs but it does mean the patient has a safety net in place with a Physician Trained Anesthesiologist avail. as back-up.

3. Solo Practices- If this means "All MD" anesthesia then yes that model may not be cost effective in the future. However, the ACT/Supervision model is indeed cost-effective and perhaps, the safest model for patient care. But, practices which encourage "Independent" CRNA providers to go solo without any input from Anesthesiologists is NOT going to be the norm anytime soon. The quality of Nurse Anesthesia graduates simply isn't up to par for such a National model.

4. Reimbursement- Indeed the future is less money for all involved in Anesthesia. But, the money issue must not come before the "quality" issue of a Board Certified Anesthesiologist as "Team Leader" in a hospital setting. Despite the rhetoric from the other side I seriously doubt most instititutions are going to OPENLY allow Independent CRNA practice anytime soon.

5. Medical Students vs. SRNA- If the ASA/ASA PAC doesn't fight the Militant CRNAs/AANA tooth and nail over the issue of 'Independent Practice' then this field will fall into a Nursing level category. Currently, this field is MEDICINE and the CRNAs are being reimbursed (when working Solo) at a Physician level rate. When and if the field is viewed as a Nursing level function (as claimed by the AANA) the reimbursement is sure to follow driving Medical Students away from Anesthesiology.

What other Field has a branch of Nursing claiming its 100% Equivalent to its Physician level "colleague"? Even Family Medicine APNs don't go that far (yet).

Despite all the personal attacks/Ad-Hominem insults by Militant CRNAs the point of my posts is that we are under attack/seige and must fight back to maintain our Medical Specialty. Unlike any other area of Medicine the "mixed group" model is a death sentence to the Medical Specialty of Anesthesiology as we know it.
 
BLADEMDA said:
This particular individual is either ignorant or pandering to the Militant Nurse crowd. Let's examine the implications of a "mixed model" system as proposed by the AANA/Militant CRNA and compare it with other mixed models in OB/ER/ICU.

1. AANA claims "equivalency" and as such, its providers should have all the same privileges/rights as their MD (A) counterparts. This means CRNA care from start to finish with no MD(A) involvement reqired or even needed. The Mixed Model in the O.R. is EXACTLY this equivalency as it essentially involves NO MD Anesthesia involvement. Is this what E.R. Doctors face with their PAs? Does a Nurse Midwife have the "right" to do a C section when things turn ugly? Does an ER PA have the "right" to do ALL the same procedures as an ER attending?

2. The Mixed model in the ICU, ER and even OB still leaves the Physician in charge of making the critical decisions and being involved with the most difficult procedures. We have such a "Mixed Model" already in Anesthesia and it is called the "Anesthesia Care Team" approach. This doesn't mean every case must be "micromanaged" by the Attending or even that the CRNA can't push drugs but it does mean the patient has a safety net in place with a Physician Trained Anesthesiologist avail. as back-up.

3. Solo Practices- If this means "All MD" anesthesia then yes that model may not be cost effective in the future. However, the ACT/Supervision model is indeed cost-effective and perhaps, the safest model for patient care. But, practices which encourage "Independent" CRNA providers to go solo without any input from Anesthesiologists is NOT going to be the norm anytime soon. The quality of Nurse Anesthesia graduates simply isn't up to par for such a National model.

4. Reimbursement- Indeed the future is less money for all involved in Anesthesia. But, the money issue must not come before the "quality" issue of a Board Certified Anesthesiologist as "Team Leader" in a hospital setting. Despite the rhetoric from the other side I seriously doubt most instititutions are going to OPENLY allow Independent CRNA practice anytime soon.

5. Medical Students vs. SRNA- If the ASA/ASA PAC doesn't fight the Militant CRNAs/AANA tooth and nail over the issue of 'Independent Practice' then this field will fall into a Nursing level category. Currently, this field is MEDICINE and the CRNAs are being reimbursed (when working Solo) at a Physician level rate. When and if the field is viewed as a Nursing level function (as claimed by the AANA) the reimbursement is sure to follow driving Medical Students away from Anesthesiology.

What other Field has a branch of Nursing claiming its 100% Equivalent to its Physician level "colleague"? Even Family Medicine APNs don't go that far (yet).

Despite all the personal attacks/Ad-Hominem insults by Militant CRNAs the point of my posts is that we are under attack/seige and must fight back to maintain our Medical Specialty. Unlike any other area of Medicine the "mixed group" model is a death sentence to the Medical Specialty of Anesthesiology as we know it.
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Agreed - the level of CRNA militance is unmatched by other nurses. I'm currently on a rotation where the neonatology hospitalist is a DNP. yup. there is no physician working as a hospitalist - it is a DNP. Even she doesn't claim equivalency - but she does tell patients 'I'm something between a nurse and a doctor..I'm more than a nurse, but not quite the same as a doctor'

the whole time i'm wondering - how are you more than a nurse..isn't DNP = doctorate of NURSE practioning?

anyways - it it comes to real blown out war, i'm willing to blow my salary and work for 200k. I know that will terrify some of you out here, but I guess i'm doing this because i love the field. Many CRNA's out here are making 120-150k. If a physician is hired in the market at 200k, and will probably cover call and work more..who will win? will a hospital hire a group of docs at 200k per doc, or a group of nurses at 130-150k per nurse? esp given the liability a physician can shoulder that nurse groups are unlikely to - many CRNA's aren't militant and don't want that liability - and if dropping physician salaries bring CRNA salaries back to where they belong ( 70-80k ), it kind of takes the charm out of being a CRNA, doesnt it?

that's the worst case scenario I see, so far. correct me if i'm wrong.
 
BLADEMDA said:
15 January 2011 02:47
Elizabeth WT


I am a practicing CRNA for 15+ years and think this debate has gone completely crazy. First of all, to the other CRNAs who are salivating at the prospect of running the show by themselves, be careful what you wish for. We do not take call like MDs, our hours are better, and if you actually look at the per hour salary, we are closer to anesthesiologists than you realize. Secondly, I can honestly say I would not be the competent CRNA that I am today were it not for the vigilant supervision and teaching that anesthesiologists have provided me over the years. So many times in my career, the you know what has hit the fan, and the anesthesiologist has come to the rescue and prevented me from looking like an idiot. Sure, I feel confident now and can do many ASA1 and ASA2 cases without much supervision. However, knowing that an anesthesiologist is around the corner to help is something I think is genuinely better for the patient. Let's be honest here. The anesthesiologists did go to medical school and residency, so obviously they are going to have more knowledge and skills than we have. That being said, I do not appreciate the belittling that some physician groups have done towards CRNAs --- we are an essential and valuable part of the anesthesia team and should be treated accordingly. The badgering that is going back and forth is ultimately all about money and should be about patients. Do I think we should be supervised? --- yes. Do I think we should be treated as useless technicians? --- no. We need to increase the dialogue and be respectful for our patients sake.

Elizabeth WT
CRNA
Maryland
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This is a fantastic approach. If more CRNA's treated anesthesiologists with this level of respect and basic common sense i don't think there would be so much animosity. There is obviously a place in the anesthesia world for both MD's and CRNA's - it's just when one group tries to blur the lines between the two roles that we have a need for a turf war.
 
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Here are a few comments from the Feb 2011 ASA Newsletter. Jerry Cohen, MD Professor of Anesthesiology at The University of Florida:

That Old Clint Eastwood Line pops into mind every time I hear about cheaper, less-educated nurses giving anesthesia solo: "Are you feeling lucky.....?"

So we must drive home the big picture. The practice of Medicine is not the practice of Nursing. Medical Education is unique and has different aims than nursing education.....Technical skill is not the same as judgement, even when doctors and nurses share techniques.

Legal shortcuts do not make a nurse a physician.

We must constantly oppose the magical thinking that EXTENDERS can do the same thing as physicians at lower cost. Cost-effective integration of health care requires the use of teams....However we must reinforce the idea that care teams work because Physicians supervise them.
 
BLADEMDA said:
Here are a few comments from the Feb 2011 ASA Newsletter. Jerry Cohen, MD Professor of Anesthesiology at The University of Florida:

That Old Clint Eastwood Line pops into mind every time I hear about cheaper, less-educated nurses giving anesthesia solo: "Are you feeling lucky.....?"

So we must drive home the big picture. The practice of Medicine is not the practice of Nursing. Medical Education is unique and has different aims than nursing education.....Technical skill is not the same as judgement, even when doctors and nurses share techniques.

Legal shortcuts do not make a nurse a physician.

We must constantly oppose the magical thinking that EXTENDERS can do the same thing as physicians at lower cost. Cost-effective integration of health care requires the use of teams....However we must reinforce the idea that care teams work because Physicians supervise them.
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The ASA leadership and members like myself realize we are at war with the AANA and Militant CRNAs.

We can and should have an open discussion with CRNAs about this very important topic; but,they need to remove their tinfoil hats first.

Blade
 
I urge all ASA members to read this month's ASA Newsletter. Dr. Cohen and I agree 100% on this important issue.

Here is another quote from Dr. Cohen:

"Our job is to be effective advocates for the safety of our patients and policies that promote the best care possible. In the end, this is true economy."


Let's hope Obamacare doesn't end up with Second tier providers as "good enough" at our major hospitals.

Blade
 
BLADEMDA said:
I urge all ASA members to read this month's ASA Newsletter. Dr. Cohen and I agree 100% on this important issue.

Here is another quote from Dr. Cohen:

"Our job is to be effective advocates for the safety of our patients and policies that promote the best care possible. In the end, this is true economy."


Let's hope Obamacare doesn't end up with Second tier providers as "good enough" at our major hospitals.

Blade
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You can't build a $40,000 car for $10,000.
But you can make it look just like one, as long as you don't look too close.
You can also sell people on the fact that it is just as good.

That is Obamacare. It is happening in all specialties. The next step is to make it hard to impossible to buy up to the $40,000 car, even if you have the means.
 
dr doze said:
You can't build a $40,000 car for $10,000.
But you can make it look just like one, as long as you don't look too close.
You can also sell people on the fact that it is just as good.

That is Obamacare. It is happening in all specialties. The next step is to make it hard to impossible to buy up to the $40,000 car, even if you have the means.
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http://www.youtube.com/watch?v=egcIKZoNGd8
 
Interesting article recently from Health Affairs about the clinical equivalence between the care provided by anesthesiologists and CRNAs. The article concludes by advocating that CRNAs be given permission to practice anesthesiology without physician supervision. It’s more cost effective. And there is no compromise to the quality of care delivered to patients.
We recommend CMS return to its original intention of allowing nurse anesthetists to work independently of surgeon or anesthesiologist supervision without requiring state governments to formally petition for an exemption,” they conclude. “This would free surgeons from the legal responsibilities for anesthesia services provided by other professionals. It would also lead to more cost-effective care as the solo practice of certified registered nurse anesthetists increases.” The study was funded by the American Association of Nurse Anesthetists.
​
A couple of caveats. One, the study was conducted by the American Association for Nurse Anesthetists (sort of like a study claiming that Jeff Parks is the smartest man on earth being conducted by “friends and family and hired sycophants of Dr. Parks”). Also, the study admits that CRNA’s tend to work on less complex cases than MD anesthesiologists.
The main thrust of papers like this is to delve into the essence of what it means to be a “doctor.” Are all doctors alike? Is the orthopod who replaces 350 knees a year the same as the internist cranking through 30 patients a day with complex medical problems? Is it fair or unfair to further categorize the various specialties according to some sort of intellectual hierarchy? Do some specialties verge perilously close to being mere technicians, thereby inviting the sort of turf war salvo sounded by the above referenced paper?
In reality, I think it goes beyond anesthesiology (although anesthesiologists are an arguably easier target). Most of the work done by a family practitioner can probably be adequately performed by a NP or PA without adverse effects. If you trained a physically gifted person to take out gallbladders and that’s all he did, day after day, I bet you would be able to find a paper demonstrating that the non-MD surgeon has a similar complication rate as a formally trained general surgeon. But then what is that automaton going to do when he encounters a cholecysto-colonic fistula or when the cholangiogram shows he has cut the common bile duct? What is the NP going to do when she has to manage a patient with diabetes, heart disease, peripheral vascular disease, and obesity who comes into the office with abdominal pain? Would any CRNA accept the responsibility and stress of running a CABG solo?
The bottom line is, most of the time you don’t need a doctor until you really need one. But you never know when that day is going to be. You never know when that seemingly normal patient who walks into the ER ends up turning into a complete disaster. My advice to these non-doctors seeking legitimacy and complete autonomy: be careful of what you wish for.
Jeffrey Parks is a general surgeon who blogs at Buckeye Surgeon.
 
Do you think Anesthesiologists are going to go extinct if they're replaced by (lower-paid) Nurse Anesthetists?

This is from the New York Times:

"Analysts at the Research Triangle Institute found that there was no evidence of increased deaths or complications in 14 states that had opted out of requiring that a physician (usually an anesthesiologist or the operating surgeon) supervise the nurse anesthetists. The analysts recommended that nurse anesthetists be allowed to work without supervision in all states. Researchers at the Lewin Group judged nurse anesthetists acting without supervision as the most cost-effective way to deliver anesthesia care. "

http://www.nytimes.com/2010/09/07/opinion/07tue3.html

Since you can pay the Nurse Anesthetist (CRNA) half as much as the Anesthesiologist for essentially the same job, won't private clinics and hospitals opt to replace Anesthesiologists with CRNAs?
They seem to be more cost-effective, at least according to the studies.
And with the health-care reform bill, isn't there more pressure for cutting costs, too
 
Patients prefer physician anesthesiologists. This maybe true, if the costs were the same. But how many patients have been surprised by a bill from an anesthesiologist who was not in their insurance network and subsequently disputed or refused the charges? Do you think these people would feel more satisfaction with their hospital and surgeon if they got no anesthesia bill at all because the CRNA administering the anesthesia was an employee of the hospital and thus wouldn't charge the patient separately? Where is the study that shows patients prefer paying extra for an anesthesiologist or anesthesiologist-supervised CRNA vs. a free solo or surgeon-supervised CRNA? (Free meaning their insurance company pays for it.) Are we afraid to find that people would not want to pay more money to be anesthetized by an MDA or MDA-supervised CRNA? And how much more would patients be willing to pay to have an anesthesiologist instead of a CRNA give the anesthetic? $1000? $100? $10? Of course it's easy for people to tell researchers they want anesthesiologists present or nearby when the anesthetic is given. But when they have to reach deep into their own pockets for the privilege I'm willing to bet their stories will change pretty quickly. That type of study involving real money will need to be conducted to prove we are indeed preferred over CRNAs.

As a practicing anesthesiologist, and a proud member of the ASA who contributes to ASAPAC every year, it pains me to have to write these words. And it really isn't Dr. Hannenberg's fault that his arguments are so anemic. We anesthesiologists are so busy in our ivory towers trying to understand the molecular basis of lung ventilation in the name of patient safety that we have failed to see the soul of anesthesiology is being hijacked by the nurses. While the AANA is cranking out multiple papers per year on why they are at least equivalent to MDAs for less cost, we haven't produced a study demonstrating the value of anesthesiologists in today's health care environment. The nurses only need to prove they provide care as well as doctors to have an advantage, because if all else being equal, the deciding factor will be cost, their ultimate trump card. If that situation should come to pass, the only way we anesthesiologists can stay gainfully employed is if we lower ourselves to an equivalent salary. That will indeed be a sad day for anesthesiology.
 
The ASA Fiddles While Anesthesiologists Are Getting Burned





.....None of this drama appeared to trouble the celebration at the annual meeting. The president of ASA, Dr. Alexander Hannenberg, gave a written interview on the accomplishments of the ASA over the past year. The Medicare opt out problem was not even mentioned. While perusing through the meeting's thick course catalog, I didn't notice a single talk about the dangers of CRNA's practicing independently of anesthesiologists. Not one breakfast meeting, panel discussion, or symposium was held on how anesthesiologists are slowly and inexorably losing their profession to nurse anesthetists.

By contrast, the nurses really have their acts together. They trumpet their self-sponsored "studies" that tout the safety of their practices that are readily picked up by the mass media. They have strong state and national organizations that are able to persuade government officials to see these issues their way over the objections of the states' doctors. The CRNA's even have meetings that teach the proper method for developing relationships with elected officials.

Where is the urgency to hold back this onslaught? While the ASA elite mingle and laugh it up, anesthesiologists are inexorably being corralled into isolated urban hospital settings. In the meantime the suburban and rural jobs, where two-thirds of surgical cases are done, are being usurped by CRNA's. The ASA calls these opt out decisions by the likes of Gov. Ritter and Gov. Schwarzenegger politically motivated. That raises the troubling question of why the ASA and physicians in general are so politically disconnected and impotent when compared to the AANA, the trial lawyers, or the government employee service unions. The ASA trumpets their accomplishment in reversing the Medicare teaching rule bias against anesthesiology residencies, but if these residents don't have anywhere to practice when they graduate, the whole battle would have been Pyrrhic indeed. We can try to convince the CMS about the unfairness of Medicare reimbursements to anesthesiologists, but at the end of the day, if we don't have jobs to go to, the viability of anesthesiologists will be in doubt.
 
BLADEMDA said:
I urge all ASA members to read this month's ASA Newsletter. Dr. Cohen and I agree 100% on this important issue.

Here is another quote from Dr. Cohen:

"Our job is to be effective advocates for the safety of our patients and policies that promote the best care possible. In the end, this is true economy."


Let's hope Obamacare doesn't end up with Second tier providers as "good enough" at our major hospitals.

Blade
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I thought Cohen's piece was awesome. There were 4 articles in the newsletter regarding CRNAs, and the active fight against them.

Sounds like Blade's wisdom is continuing to resonant amongst the ASA leadership, and continuing to scare the militant-mursey.org troll boys.

Combine the power of Blade's battlecry and the most powerful medical PAC on Capitol Hill and you have recipe for BIG change.

Keep up the good work. :thumbup:
 
CRNAs at work
On the job, CRNAs talk with patients before surgery and glean some history. They use anesthetics to put patients to sleep and manage their pain; they monitor vital signs throughout the procedure, awaken patients and inquire about their pain status afterwards. They must be compassionate, detail-oriented and willing to work swing shifts.
"It's not a cookbook," Bahagry said. "We plan and design an anesthetic according to the patient, their health care and the procedure they are having." CRNAs may work without the supervision of anesthesiologists, and most in rural areas do so. In addition to hospitals, they may also work in dental, oral surgery, orthopedic, pain management, ophthalmology, endoscopy or fertility clinics. Hospital salaries in the Twin Cities start at around $140,000 and the local job market is tight, according to Moody. Clinic salaries may be higher and rural jobs more plentiful.
"We love what we do," Bahagry said. "You feel a sense of fulfillment just going to work and taking care of patients."


http://www.startribune.com/jobs/healthcare/115139794.html
 
Coastie said:
I thought Cohen's piece was awesome. There were 4 articles in the newsletter regarding CRNAs, and the active fight against them.

Sounds like Blade's wisdom is continuing to resonant amongst the ASA leadership, and continuing to scare the militant-mursey.org troll boys.

Combine the power of Blade's battlecry and the most powerful medical PAC on Capitol Hill and you have recipe for BIG change.

Keep up the good work. :thumbup:
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I agree. It IS resonating out there. I was recently told by a senior CRNA (not a malignant person, but I don't know her well enough to know if she's militant in her views/actions) that "this place used to be a great place to work until a few years ago" and that "this group is very controlling".

Ofcourse this was all stated just matter of fact. She went on to say that when partners get word of a SRNA doing a line (central line) and the other partners get wind of this, the hammer comes down. Same with epidurals.

You know what? It should friggin come down. If this CRNA brings that sh.t up to me again, I'll politely suggest what I've thought for years. The AANA just may get what's coming to them. I'll bring up the fact that "perhaps this is in response to the antagonism promoted by the AANA for years, and that these "policies" are in reaction to the constant propaganda from the AANA"......

Enough is enough, and it gave me great pleasure to hear that our leadership has the balls to institute these policies. Indeed, on labor and delivery the other day, our program director (placing an epidural with nurses setting up the infusion pump and assisting as needed in stabilizing the patient or whatever) says, as he's drawing up fentanyl for the spinal, "it's never good to stick the NURSE while you're doing this" (this was a CRNA).

It's sad to me that it's so bad as to NECESSITATE some degree of us versus them. But, it is what it is. More anesthesiologists need to get pissed and begin taking ownership of the direction of our field. I really think this is happening.

Once again, it's up to US.
 
Sounds like you have an amazing program.

cfdavid said:
I agree. It IS resonating out there. I was recently told by a senior CRNA (not a malignant person, but I don't know her well enough to know if she's militant in her views/actions) that "this place used to be a great place to work until a few years ago" and that "this group is very controlling".

Ofcourse this was all stated just matter of fact. She went on to say that when partners get word of a SRNA doing a line (central line) and the other partners get wind of this, the hammer comes down. Same with epidurals.

You know what? It should friggin come down. If this CRNA brings that sh.t up to me again, I'll politely suggest what I've thought for years. The AANA just may get what's coming to them. I'll bring up the fact that "perhaps this is in response to the antagonism promoted by the AANA for years, and that these "policies" are in reaction to the constant propaganda from the AANA"......

Enough is enough, and it gave me great pleasure to hear that our leadership has the balls to institute these policies. Indeed, on labor and delivery the other day, our program director (placing an epidural with nurses setting up the infusion pump and assisting as needed in stabilizing the patient or whatever) says, as he's drawing up fentanyl for the spinal, "it's never good to stick the NURSE while you're doing this" (this was a CRNA).

It's sad to me that it's so bad as to NECESSITATE some degree of us versus them. But, it is what it is. More anesthesiologists need to get pissed and begin taking ownership of the direction of our field. I really think this is happening.

Once again, it's up to US.
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ProRealDoc said:
I actually recognized some names on that list of individual CRNAs I came accross during residency.
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Remember that the list only includes those who give $200 or more. Less than that doesn't have to be publicly disclosed.
 
I notice several names are listed multiple times, often with the same amounts. Does that just mean multiple donations? Is there a max amount allowed per donation? As a resident, I'm still far from donating the max, so I don't know all the rules.

It's at least encouraging to see the growth in donations to ASAPAC, and that there are 83 pages of $200+ donations to ASAPAC vs. 18 to AANA. Still not good enough, though. With the current average income of anesthesiologists in this country, every practicing physician should have 4-figure donations if they care about the future of the specialty. I will as soon as I can afford it after residency.
 
From AANA.com.....


Most programs exceed these minimum requirements. In addition, many require study in methods of scientific inquiry and statistics, as well as active participation in student-generated and faculty-sponsored research.
Clinical residencies afford supervised experiences for students during which time they are able to learn anesthesia techniques, test theory, and apply knowledge to clinical problems
The CRNA scope of practice includes, but is not limited to, the following:
(a) Performing and documenting a pre-anesthetic assessment and evaluation of the patient, including requesting consultations and diagnostic studies; selecting, obtaining, ordering, or administering pre-anesthetic medications and fluids; and obtaining informed consent for anesthesia.
(b) Developing and implementing an anesthetic plan.
(c) Selecting and initiating the planned anesthetic technique which may include: general, regional, and local anesthesia and intravenous sedation.
(d) Selecting, obtaining, or administering the anesthetics, adjuvant drugs, accessory drugs, and fluids necessary to manage the anesthetic, to maintain the patient's physiologic homeostasis, and to correct abnormal responses to the anesthesia or surgery.
(e) Selecting, applying, or inserting appropriate non-invasive and invasive monitoring modalities for collecting and interpreting patient physiological data.
(f) Managing a patient's airway and pulmonary status using endotracheal intubation, mechanical ventilation, pharmacological support, respiratory therapy, or extubation.
(g) Managing emergence and recovery from anesthesia by selecting, obtaining, ordering, or administering medications, fluids, or ventilatory support in order to maintain homeostasis, to provide relief from pain and anesthesia side effects, or to prevent or manage complications.
(h) Releasing or discharging patients from a post-anesthesia care area, and providing post-anesthesia follow-up evaluation and care related to anesthesia side effects or complications.
(i) Ordering, initiating or modifying pain relief therapy, through the utilization of drugs, regional anesthetic techniques, or other accepted pain relief modalities, including labor epidural analgesia.
(j) Responding to emergency situations by providing airway management, administration of emergency fluids or drugs, or using basic or advanced cardiac life support techniques.
 
Art Zwerling, DNP, CRNA DAAPM

zwerling.jpg

I was the Program Director for the University Of Pennsylvania School Of Nursing, and Pennsylvania Hospital Nurse Anesthesia Programs in Philadelphia. I currently maintain a full-time clinical practice at Fox Chase Cancer Center as Chief CRNA, with a focus on general, urologic, gynecologic and thoracic anesthesia, and with an additional focus on acute and chronic pain management.
It is my professional goal to provide every FCCC patient with an optimal,
patient focused, individualized anesthetic and pain management



zwerling.jpg
 
Militant CRNA Speaks Out:


If you are not a CRNA (which I know that
you are not) then clearly you have no reason to comment on Dr. Z's work or
affiliation with anesthesia, the AANA, or his stand against anesthesiologist. He
is trying to advance Nursing Anesthesia. Period! It is enough that he is being
met with so much resentment from the anesthesiologist but he sure don't need to
have any backlash from CRNA hopefuls, nurse hopefuls, or nurses period. What you
should be doing is giving him the props for going against those greety pig$ and
taking a stand for nurse anesthesia. Without people like him, nursing anesthesia
would not have advanced to where it is today. With that not happening I am sure
that you would not even be on this board because you would def. not have an
interest in nursing anesthesia (i'm willing to bet a million bucks). So show
some respect and dignity. At least pretend that you are here for the greater
good of anesthesia. Dr. Z's credentials are far beyond what many nurses dream of
achieving. He has a doctorate, 2 master degrees, and advanced training in pain
mangement (DAAPM) out side of his RN degree. So like many have said, he is well
qualified to speak on behalf of the subject at hand. Another thing, If people
call him doctor in the clinical setting it is not misrepresenting himself. He
has a doctorate degree and deserves to get called such. He is a doctor (a doctor
of Nuring). He is not a physician and thats where the difference lies. The
patients don't know dittly swat of who is treating or caring for them anyway.
Its not the patients that give a hoot, it the physicians that care so about it
because they think someone is stepping on thier toes and they are the all mighty
and who dares to try to come close. Please!! This is not 1940! Healthcare and
Nursing is advancing. I am very proud to have someone to fight the war to better
my future profession. Lastly, the white coat thing you said.............I guess
we need to tell the janitors and the clerks to stop wearing scrubs because they
look like nurses. While we are at it, lets tell the lab techs too so they won't
be confused as physicians, nurses, or pharmacist
 
MD (A)

"I think it's time for me to level with you. Doctors are cut from a different cloth than nurses. Doctors and nurses attended the same high schools, but that's where our common paths ended. With little exception, we achieved greater success in high school. We got higher SAT scores. We attended the more competitive colleges (I'm a UNC grad myself, which is regularly ranked in the top 30 but still among the less-prestigious undergraduate institutions attended by my med school classmates). But it doesn't stop there. We had to achieve high grades at our respective colleges, which meant competing against other top-notch students. It doesn't matter where you go. Anything under than a 3.4, and you're not getting into medical school unless you know somebody. Then there's the MCAT. I'd love to see how many nursing students could achieve a competitive score on the MCAT. The national average is a 24. The average for medical school matriculants is 30. Then there's med school itself. You will never be able to comprehend the amount of material we are responsible for learning. There is no way I can describe it to you. College was much harder than high school, but medical school is in a totally different world. Any words I use to describe how challenging medical school was won't effectively describe it for you. Then there is the USMLE; the hardest exam I ever took in my life. Anesthesiology isn't the most competitive specialty out there, but it's pretty damn competitive. They want graduates in the top 3rd of their medical school class, and a Step 1 score well above the national average. So, anesthesiologists are truly the almost-best of the best of the best. And to top it all off, some anesthesiology programs are more competitive than others. Moreover, there are even competitive fellowships! Yeah, CRNA students are the creme of the crop in their profession of nursing, but they're the cream of a lesser crop. Are there exceptions? Are there CRNAs who more academically-gifted than anesthesiologists? Sure! There are exceptions to everything. But not many. Virtually all medical students had to achieve what I did to get into medical school. And virtually every anesthesiologist had to achieve what I did to become anesthesiologists. Like I said, we are cut from a different cloth than our CRNA counterparts. That sounds harsh, it sounds arrogant, but you know it's true. By and large, the most academically-gifted students in high school are far more likely to end up in medicine than in nursing."

Nurse Response:

I have enjoyed your posts very interesting read. I find your presumed intellegence funny. I did a return on investment while deciding on going to med-school or nursing. You may be a great doctor but like most a crummy business man. The amount of schooling, hours of training, work hours and school loans don't add up. I went to nursing school and worked in ER, ICU and by the age of 30 was in medical sales. Needless to say a generally lower stress less hours good money job. Frankly I get paid alot of money training overworked doctors on medicare guidelines and new evidence in their field.
Actually some of my coworkers are doctors tired of the rigors of the profession they chose.
SO tell me again how bright you have to be to be a physician. Oh yeah I almost forgot how do you think this new healthcare plan willl affect your reimbursement? Would you like a clinician business man to break that down for you? You will not do very well and I hope the loans are paid off and you kept the Honda you drove through residency. Just my 2 cents.
​
 
Last edited:
Why doctors don’t get rich



Doctors need financial treatment

“Physicians have a significantly low propensity to accumulate substantial wealth.” – Thomas Stanley, author of The Millionaire Next Door
How come doctors fail to get rich? I’ve identified six reasons based on observations working with my physician clients.
A late start
By the time doctors finish medical school and residency they’re typically in their middle or late thirties. Many have families to feed, and substantial student loans to pay off. It will be years before they can even start accumulating wealth.
Challenging environment
It is increasingly challenging to practice medicine. With the Medicare Trust Fund slated to go bust in 2019, the Center for Medicare and Medicare Service (CMS) is increasingly resorting to cutting physician reimbursements and implementing bundled payments.
Lifestyle expectations
Society expects a doctor to live like a doctor, dress like a doctor, and drive like a doctor. Meeting social expectations can be quite expensive.
Time and energy
A doctor can’t be just a doctor any more. He and she also has to deal with ever increasing regulatory mandates, paperwork requirements by capricious insurance companies. The demand on their time is mind-boggling. A typical doctor works a ten- to twelve-hour day. After work and family, they simply don’t have time and energy left to do proper financial planning.
Financially naïve
Doctors are smart. They’re highly trained in their area of expertise. But that doesn’t translate into understanding about finance. Because they are smart, it’s easy for them to think they can easily master the field of finance as well. They can’t.
Lack of trust and delegation

Many doctors don’t trust financial advisors working for major Wall Street banks. They have the good instinct to realize that their interests are not aligned. Not knowing there are independent advisors out there who observe a strict fiduciary standard, they tend to do everything by themselves.
 
We cannot keep good people in anesthesiology if "Obamacare" threatens to cut reimbursement down to medicare rates. The truly gifted won't stay in the field nor will they enter it. We already had this demonstrated about ten years ago after a downturn in the anesthesia job market. Medical students diverted into other specialities and the candidate pool shrank. Those who would not normally have been trained as anesthesiologists were accepted into training. When it became time for those to graduate, we were quietly warned that class of residents was not recommendable for hiring. Anesthesiology requires top quality people to maintain patient safety. You might recover and get a second chance if a mistake is done by someone in another profession, but in anesthesiology you really want it done right EVERY time.

My anesthesia group has been fortunate enough to select and retain only the best. Only when in actual practice do you really see that anesthesiologists are not all the same. They vary in skill, knowledge, effectiveness during emergencies, and degree of ethical conduct. As a patient, you want the best. Yes, a lesser, perhaps willing to work for cheaper, practitioner may be survivable 95% of the time, but during intraoperative emergencies, is that who you want safeguarding your loved ones? It is not always a clear disaster that shows the differences between a superior provider and a mediocre one. Things may simply go less than optimally because of poor skill or planning. You were unconscious and never knew how close you came to calamity.

Guy Kuo, MD
 
BLADEMDA said:
Nurse Response:

I have enjoyed your posts very interesting read. I find your presumed intellegence funny. I did a return on investment while deciding on going to med-school or nursing. You may be a great doctor but like most a crummy business man. The amount of schooling, hours of training, work hours and school loans don't add up. I went to nursing school and worked in ER, ICU and by the age of 30 was in medical sales. Needless to say a generally lower stress less hours good money job. Frankly I get paid alot of money training overworked doctors on medicare guidelines and new evidence in their field.
Actually some of my coworkers are doctors tired of the rigors of the profession they chose.
SO tell me again how bright you have to be to be a physician. Oh yeah I almost forgot how do you think this new healthcare plan willl affect your reimbursement? Would you like a clinician business man to break that down for you? You will not do very well and I hope the loans are paid off and you kept the Honda you drove through residency. Just my 2 cents.
​
Click to expand...
Good grief. The shaming language and ego are strong with this one.

At my level of training, I am trying my best to keep neutral until I have been in the thick of things for a couple of years, and form a stronger opinion in either direction. But reading things like this make me think these people need a serious reality check on the skills they actually have and what they perceive they have.

And what does experience in medical sales have to do with the practice of medicine? Did he run the business, or was he just a drug/sales representative? Big difference between the two.

I have caused CRNA's to go into visible panic in Crisis Management courses on SIMULATORS that residents would just walk through.
 
Seriously, folks like this sound like complete a-holes whether they realize it or not. It's no different than me bashing a firefighter for being such a "stupid businessman" putting his life on the limb, taking call at the firehouse, having good chance of ending his career on disability...all for a pittance while we're all laughing our way to the bank starting housefires. There is always something of self-sacrifice and altruism with any medical career, regardless of reimbursement. Let's see how much this guy is thankful for doctors when his organs starting failing and he wants to eke out a few more years of his oh-so-charmed life in medical sales. And on the flip side, would be great to see how much he'd be eating crow if salaries were to drop to such an extent that he's waiting on an anesthesiologist before he can get that surgery he wants.

Ronin2258 said:
Good grief. The shaming language and ego are strong with this one.

At my level of training, I am trying my best to keep neutral until I have been in the thick of things for a couple of years, and form a stronger opinion in either direction. But reading things like this make me think these people need a serious reality check on the skills they actually have and what they perceive they have.

And what does experience in medical sales have to do with the practice of medicine? Did he run the business, or was he just a drug/sales representative? Big difference between the two.

I have caused CRNA's to go into visible panic in Crisis Management courses on SIMULATORS that residents would just walk through.
Click to expand...
 
Even if I don't go into anesthesiology, I will donate to the ASA PAC. Some of the things these CRNA's say is infuriating to any physician of any specialty. They wouldn't be where they are without anesthesiologists. If they are so great and all knowing, why don't they train their SRNA's. I am truly scared of the future if anesthesiology takes another hit like it did in the 90's, because it may never recover thanks to the CRNA. I will dread surgery for myself and loved ones.
 
BLADEMDA said:
Art Zwerling, DNP, CRNA DAAPM

zwerling.jpg

I was the Program Director for the University Of Pennsylvania School Of Nursing, and Pennsylvania Hospital Nurse Anesthesia Programs in Philadelphia. I currently maintain a full-time clinical practice at Fox Chase Cancer Center as Chief CRNA, with a focus on general, urologic, gynecologic and thoracic anesthesia, and with an additional focus on acute and chronic pain management.
It is my professional goal to provide every FCCC patient with an optimal,
patient focused, individualized anesthetic and pain management



zwerling.jpg
Click to expand...

"Chief CRNA, with a focus on general urologic, gynecologic, and thoracic anesthesia, and with an additional focus on acute and chronic pain management".

....That's rich! A nurse with a "focus"! Kinda reminds me of Andy Dufresne from "The Shawshank Redemption" referring to his fellow prisoners as "co-workers". The concept of there being a "chief CRNA" is comical enough, but saying that a nurse-anesthetist has a focus.....that's just side-splittingly funny!

What makes this murse's claim of having a "focus" entirely laughable is the fact that, in order to have a focus in any specialty discipline, you have to have people who refer to you patients for said disciplines. In the case of medicine we have fellowships, and it is the fellowship-trained physicians who can consider themselves as having a "focus". Hell, sometimes fellowship training isn't enough. Some pediatric ENTs have greater training in certain areas of peds ENT, and on that basis will garner recognition as having a "focus" and receive referrals for those areas. But who the hell refers any patient to a mid-level provider for a specialty need? Other mid-levels? I guess murses don't need any of that. The simple state of thinking thoracic anesthesia is neat-o-torpedo is enough for this a-hole to consider himself as having a "focus".

Calling this guy a charlatan wouldn't be accurate. He's an absolute clown!

Someone should tell these nurses that wearing a long white coat and scrubs, sticking a bunch of letters behind their names, claiming that they do "residencies" and have "specialties", and hell.....even calling each other "doctor".....won't make them doctors. No matter how hard they try. No matter how much they try to white-wash their educational history and bloat their training with fancy words, they will never, ever be the same as a doctor without going to medical school.
 
Last edited:
Ronin2258 said:
Good grief. The shaming language and ego are strong with this one.

At my level of training, I am trying my best to keep neutral until I have been in the thick of things for a couple of years, and form a stronger opinion in either direction. But reading things like this make me think these people need a serious reality check on the skills they actually have and what they perceive they have.

And what does experience in medical sales have to do with the practice of medicine? Did he run the business, or was he just a drug/sales representative? Big difference between the two.

I have caused CRNA's to go into visible panic in Crisis Management courses on SIMULATORS that residents would just walk through.
Click to expand...

More BS from nurses. The reality is quite a bit different.

My father is an ENT. He lives in a 7000+ square foot home and drives a Mercedes S-class. He's rich. My brother is an internist. Not rich like my father. He only lives in a 4000+ square-foot home and drives a BMW 3-series....while raising two daughters. Neither of their wives work.

The reality is that, despite the moaning and groaning, all physicians make good incomes. Some certainly do much better than others, but all physicians live well. Medicine may not be as lucrative as it was before, but it's still lucrative enough for it to be the single-most competitive type of graduate school in which to gain admittance.
 
FutrrENT said:
“Chief CRNA, with a focus on general urologic, gynecologic, and thoracic anesthesia, and with an additional focus on acute and chronic pain management”.

....That’s rich! A nurse with a “focus”! Kinda reminds me of Andy Dufresne from “The Shawshank Redemption” referring to his fellow prisoners as “co-workers”. The concept of there being a “chief CRNA” is comical enough, but saying that a nurse-anesthetist has a focus.....that’s just side-splittingly funny!

What makes this murse’s claim of having a “focus” entirely laughable is the fact that, in order to have a focus in any specialty discipline, you have to have people who refer to you patients for said disciplines. In the case of medicine we have fellowships, and it is the fellowship-trained physicians who can consider themselves as having a “focus”. Hell, sometimes fellowship training isn’t enough. Some pediatric ENTs have greater training in certain areas of peds ENT, and on that basis will garner recognition as having a “focus” and receive referrals for those areas. But who the hell refers any patient to a mid-level provider for a specialty need? Other mid-levels? I guess murses don’t need any of that. The simple state of thinking thoracic anesthesia is neat-o-torpedo is enough for this a-hole to consider himself as having a “focus”.

Calling this guy a charlatan wouldn’t be accurate. He’s an absolute clown!

Someone should tell these nurses that wearing a long white coat and scrubs, sticking a bunch of letters behind their names, claiming that they do “residencies” and have “specialties”, and hell.....even calling each other “doctor”.....won’t make them doctors. No matter how hard they try. No matter how much they try to white-wash their educational history and bloat their training with fancy words, they will never, ever be the same as a doctor without going to medical school.
Click to expand...

The concept of CRNA's doing pain management is a real hot-button topic at the moment. Shocking as you might find this, CRNA's are actually taking referrals from physicians and other CRNA's to do a variety of pain management procedures, from simple LESI's to pain pumps. A recent past president of the AANA does pain management procedures for a group of neurosurgeons. Fortunately, many states are wising up and the push is on to make sure that chronic pain management is defined as the practice of medicine and not within the realm of nurse anesthesia practice.
 
jwk said:
The concept of CRNA's doing pain management is a real hot-button topic at the moment. Shocking as you might find this, CRNA's are actually taking referrals from physicians and other CRNA's to do a variety of pain management procedures, from simple LESI's to pain pumps. A recent past president of the AANA does pain management procedures for a group of neurosurgeons. Fortunately, many states are wising up and the push is on to make sure that chronic pain management is defined as the practice of medicine and not within the realm of nurse anesthesia practice.
Click to expand...

There are inconsiderate dirtbags that often create anecdotal ‘exceptions to the rule’, but by-and-large mid-level providers are not considered to be recipients of referrals for specialty care.
 
FutrrENT said:
There are inconsiderate dirtbags that often create anecdotal ‘exceptions to the rule’, but by-and-large mid-level providers are not considered to be recipients of referrals for specialty care.
Click to expand...

My point is that they are already doing this, and unfortunately, it's a growing trend. Mr. Zwerling that has been pictured above is one of the national leaders in the push for CRNA-administered chronic pain management.
 
Wow. That is just crazy and it needs to stop. How can a nurse be placing pain pumps? It takes an anesthesiologist 5 years of specialized training + 4 years of medical school to get there. That is just about a decade of training, effort, sweat and a ton of sacrafice.
Is he also managing them in his pain clinic? Ridiculous that this practice even exists. I don't understand how a hospital would let a nurse do chronic pain on their own. How did they get there in the first place???

I get sad when I see this sort of thing going on.

Such BS:

http://www.crnabiz.com/CRNAbiz.com/Front_Page/EBCF3C10-39C9-4F4E-9690-8F6493328310.html
 
jwk said:
My point is that they are already doing this, and unfortunately, it's a growing trend. Mr. Zwerling that has been pictured above is one of the national leaders in the push for CRNA-administered chronic pain management.
Click to expand...

Dude. If I were the national leader in the male gender’s push for morning hand-jobs by big-breasted blondes at every place of work, it still wouldn’t mean much.

As long as you guys get your act together and stomp these nurses out, people like Ms. Zwerling will not be viewed as leaders, but rather, as nuts promoting pipe-dreams.
 
As abhorrent as I find the push for CRNA pain management to be, I think that using phrases like "murses" and "Ms. Zwerling" ill represents us as a group of professionals.

Getting uppity about the phrase "MDA" (which you should) is a little weak sauce if you're calling them "murses" in the next breath.

We can fundamentally disagree with the basic premise that a nursing board can declare anything in the realm of medicine to be within the scope of nursing and therefore claim it as an opportunity for practice explansion, but let's keep the debate and our opposition professional.
 
BLADEMDA said:
Nurse Response:

I have enjoyed your posts very interesting read. I find your presumed intellegence funny. I did a return on investment while deciding on going to med-school or nursing. You may be a great doctor but like most a crummy business man. The amount of schooling, hours of training, work hours and school loans don't add up. I went to nursing school and worked in ER, ICU and by the age of 30 was in medical sales. Needless to say a generally lower stress less hours good money job. Frankly I get paid alot of money training overworked doctors on medicare guidelines and new evidence in their field.
Actually some of my coworkers are doctors tired of the rigors of the profession they chose.
SO tell me again how bright you have to be to be a physician. Oh yeah I almost forgot how do you think this new healthcare plan willl affect your reimbursement? Would you like a clinician business man to break that down for you? You will not do very well and I hope the loans are paid off and you kept the Honda you drove through residency. Just my 2 cents.
​
Click to expand...

“It is not the critic who counts, not the man who points out how the strong man stumbled, or where the doer of deeds could have done better. ​

​
The credit belongs to the man who is actually in the arena; whose face is marred by dust and sweat and blood; who strives valiantly; who errs and comes short again and again; who knows in the end the triumph of high achievement; and who, at the worst, if he fails, at least he fails while daring greatly, so that his place shall never be with those cold and timid souls who knew neither victory nor defeat."
​
​
​

Theodore Roosevelt​
 
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