Anesthesiologists with CCM scope of practice?

Discussion in 'Anesthesiology' started by soxman, Apr 25, 2007.

  1. soxman

    soxman Junior Member
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    Whats the difference in the scope of practice for anesthesiologists with CCM compared to Pulm + CCM and surgery and CCM? I could find many jobs out there for anesthesia and CCM but found tons for Pulm+ CCM.

    Also can an MDA with CCM practice anesthesiology in the OR at the same hospital where he/she is working as a CCM physician?

    Finally, how is the lifestyle for Anesthesiologists with CCM?


    Thanks
    Sox
     
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  3. jeesapeesa

    jeesapeesa anesthesiologist southern california
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    i have been told that practices which involve anesthesia + ccm in the same facility are few, but they are indeed out there. i guess most practices are strictly ccm or anesthesia. anesthesia/ccm usually tend the SICU and pulm/ccm are usually micu, but i've seen groups of ccm docs with anesthesia and pulm trained physicians tending all the ICUs. ccm usually pays less than anesthesia, but if you love that kind of thing you'll be a much much better physician that's well-rounded in all aspects of care.
     
  4. jeesapeesa

    jeesapeesa anesthesiologist southern california
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  5. johankriek

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    they all do the same thing in the ICU,, however a surgeon may do cases in the OR, gallbladder, hernia, abd washout etc etc.... a pulmonary physician may do fiberoptic bronchoscopy with biopsy and that sort of thing.. but they all can do swans, line changes, insert temp dialysis catheter, changing lines over a wire, arterial puncture, vent management, central line placement...the list goes on and on...
     
  6. toughlife

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    The anesthesia attendings I worked with in the CTICU were doing fiberoptic bronchoscopies and echos. 6 months into my intership, I had already placed all the lines you mention except any IJs.
     
  7. fakin' the funk

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    No offense, but aren't 4 of these things the same? I hope being a CCM doc isn't just placing/replacing lines.
     
  8. FirstAid

    FirstAid New Member
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    I've seen CCM docs perform these procedures as well: chest tubes, tracheostomies, and bedside TEE (again, depending on the extent of fellowship training). The ones that did bedside TEE usually had a cardiac gas fellowship (gas doc) or cardiology fellowship (IM doc) under their belt as well. So if you include these with intubations, bronchoscopies and other invasive procedures, CCM docs tend to have a pretty nice repertoire of procedures including the usual art-lines, central lines, Swan Ganz, etc.
     
  9. VolatileAgent

    VolatileAgent Livin' the dream
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    no. it also means intepreting and managing them. putting in a line just demonstrates the ability to perform a technique.

    remember, doctors (as opposed to nurses and even advanced practice nurses) are mainly paid for making decisions and taking the legal and ethical responsibility, both to the patient and the state medical board, for those decisions. a lot of people know how to "do" these tasks; taking responsibility in every sense of the word is a different ballgame.
     
  10. rmh149

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    Sorry, but I have to disagree. When I as a CRNA perform these tasks such as CVL placement, PA lines, Art lines, I am making decisions and taking full legal and ethical responsibility. You are right, performing the task is easy, using the data to better the outcome of the patient is another. And yes, as a CRNA I have to interpret the data....do you think my surgeon is going to pay attention to whats going on behind the curtain. They rely on us and are confident in our abilities. No, there are no supervising anesthesiologists at our hospital. They practice seperately from us....doing their own cases. Its a good system.

    I dont want to start a CRNA bashing thread. I just want to provide accurate information. CRNA's are more than just technicians. Of course if the supervising anesthesiologist (notice I didnt say MDA :) ) prefers to use them in that role...well then I guess those CRNA's in that group do practice as technicians. I dont have a problem with that either, their choice.

    Keep in mind, I am here to provide the point of view from a CRNA....not fight.
     
  11. ecCA1

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    "I am making decisions and taking full legal and ethical responsibility."

    The surgeon is not essentially co-signing your orders and PA lines, etc.? Are you saying that CRNAs at your hospital don't have ANY physician oversight? If so, what hospital are we talking about?
     
  12. rmh149

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    We are a CRNA group credentialed at the hospital the same way a physician group is (Dont take that statement the wrong way....we dont portray ourselves as doctors). We have to request for privilages to practice under our own license...nobody elses.

    If the physician for their patient needs a CVL in the ICU and I am in the hospital, I put it in. He doesnt need to be there or co-sign my orders. None of my orders are co-signed. When I am providing anesthesia for the surgeons patients, there is never a co-signature anywhere. I am the only one responsible for my anesthetic...that includes CVL, A-lines, etc. So no...essentially, there is no physician oversight for what I do as an anesthetist.

    The MAIN difference between a physician and US is we cannot admit, discharge, diagnose or treat. Thats the physicians responsibility. We help physicians take care of thier patients. It is part of our oath (wow, I actually am using the Nightingale Pledge). :/

    I strongly believe that our surgeons choose us over the anesthesiologists available to them because of our complete dedication to helping them care for their patients. We respect them for the doctors that they are and will do anything to make their lives easier....not to mention the lives of their patients. And we are proud of doing it for them.

    I know you hate this, but the surgeons frequently consult us to read 12 Lead EKG's, evaluate a patient for them to determine necessary diagnostics to clear them for surgery, and conult us for anything related to maintaining homeostasis in their patients postoperatively. Not trying to be a smart ass here guys...but were not as dumb as you think. Our surgeons know it and they take advantage of it. We learn alot from them and they also learn from us....but we NEVER forget that they are the physician for their patient.

    All this said....trust me when I say we DO NOT walk around and act like doctors or demand the same respect as doctors. I go by my first name...and I call all doctors "Dr. X". Its a tradition that I am used to. Also, I always introduce myslef as a CRNA or Nurse anesthetist.....never just ANESTHESIA. I dont want my patients to think I am an anesthesiologist. That would be wrong. I want them to know who is taking great care of them.
     
  13. VolatileAgent

    VolatileAgent Livin' the dream
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    this is something you have been led to believe. but, the fact is that there is always a layer above you that is responsible for your actions. in essence, the buck doesn't stop with you. and, whether or not you realize this, there is a reassurance to your actions that someone else will ultimately be responsible for what you do. if you don't know how to solve a problem or get stuck, you always have the opportunity to defer - and that deference is a huge safety net to your perceived free reign of practice.

    physician training in residency is geared towards full independence of practice and all of the responsibility that comes with that. i don't expect you to be able to comprehend or even be able to appreciate that. i don't think your training, as advanced and expert as it may be, has ever geared you to be able to "get" that on a visceral level.

    there are times in every physician's practice, when faced with many potentially appropriate clinical avenues to pursue, there is the moment of "i'm not sure that this is the best next course of action is". we may seek consult, but ultimately the decision on the way to proceed - however we proceed - falls squarely on our shoulders. despite what you may believe, that is something you have never experienced. and, unless you become a physician, you never will.
     
  14. rmh149

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    As in when the ER physician calls for my help to secure an airway for an unstable, full stomach, 350lb woman in renal failure whos O2 saturation drops to nothing in a matter of seconds....and when there is no air moving just prior to VT....you think I dont take full responsibility in my actions. No, I couldnt punt to a physician. If this woman was going to live it was going to be because of what I was going to do.....trust me it was a lonely feeling and scared the hell out of me. I took full responsibility and will continue to do so as long as I practice. I cant get stuck....or have a problem I cant solve. I am alone in my anesthetic, period.

    By the way....I did get a tube in...she survived, just in case you were wondering. whew!
     
  15. Sevo

    Sevo Senior Member
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    Sounds like you're practicing medicine, which is not within the scope of your nursing license unless directly supervised by a physician. I'm assuming that your supervising physician in this case, whether he knows it or not, is the cardiothoracic surgeon.

    Physician anesthesia (in other words the ASA) has made two big mistakes in the last forty years. Three, if one includes the fact that the ASA stood by and allowed medicare unit reimbursement to only be roughly 25-30% of commericial rates, whereas it's 70-80% for most other fields. The first was to continue to actively train CRNAs, knowing full well that in large numbers they would eventually become an economic threat in the future, because of the money they bring to academic departments and the "need to staff the ORs." The second has been to allow government recognition of practitioners of other specialties, including podiatrists, in lieu of board certified anesthesiologists as suitable "supervising physicians" for nurse
    anesthetists.

    Obviously those eye docs know how to get you out of jam when your patient goes asystolic during that cataract.
     
  16. Sevo

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  17. Sevo

    Sevo Senior Member
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    You can claim to take as much responsibility as you want, but in the end, it's the ER doctor who would've taken ultimate responsibility had you failed to secure the airway and the patient crumped. He's the doc and you're the nurse, and that's how everyone -- the family, the insurance company, the media, and the courts -- will see it.
     
  18. Sevo

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  19. The_Sensei

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    :eek:
    What Podunk, backwater burb is so isolated in the USA to allow this horror to occur? Thank God I live near civilization! My God, those poor patients have no idea!
     
  20. johankriek

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    Oh my god, this is so laughable. who needs a cardiologist when you can have a crna reading EKGs and clearing patients for surgery.. You are def delusional. I hope you dont repeat this in real life in front of anyone who has a ****ing clue. Do you even have any idea of w hat you are saying.. You sound like a child...
     
  21. johankriek

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    umm, paramedics put tubes in all the time.. does that make them capable of independent practice??
     
  22. rmh149

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    Seriously Sevo....do you think a CRNA doesn’t know what to do when a cataract patient goes asystolic? Do you think we just sit there and freeze because we are JUST nurses and don’t know how to fix a little problem like that?

    It may sound like we are practicing medicine. But we are not. We are practicing nursing. When an anesthesiologist does the EXACT same thing...its called practicing medicine. Trust me, the hospital we are contracted with was ensured legally that we are practicing within our scope of nursing practice....without supervision.
     
  23. rmh149

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  24. johankriek

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    the fact that you are calling asystole in any setting a "little problem" speaks volumes, nitecap. Now please go back to your nursing forum and tell the aspiring student nurses how much you know, nobody on this board really cares.
     
  25. rmh149

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    Sevo, you have a strong point. The doctor always takes the fall....but I would have fallen with him being a licensed practitioner that had the capability to secure the airway...but failed. My question to you is if it were an anesthesiologist that failed to secure the airway, wouldn't both of them take the fall as well.

    Your thoughts,
     
  26. rmh149

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    First of all...I have no idea who nitecap is. I assume he is a guy that really pissed some people off according to what I have read in the forums.

    Asystole happens in anesthesia. It is not a HUGE problem if you understand anatomy and physiology. Understand and stop the cause, give the right drug, and carry on.

    Seriously guys...not trying to piss off anyone. Just trying to give another point of view.
     
  27. rmh149

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    Not in a Podunk, Backwater burb. We have anesthesiologists at our hospital. They just dont want to do the things we do. As long as we are there their lives are much better.

    Our city in Texas has over 1.1 million people.
     
  28. Darwin

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    "The MAIN difference between a physician and US is we cannot admit, discharge, diagnose or treat. Thats the physicians responsibility...

    ...the surgeons frequently consult us to read 12 Lead EKG's, evaluate a patient for them to determine necessary diagnostics to clear them for surgery, and conult us for anything related to maintaining homeostasis in their patients postoperatively."

    How does one go about odering diagnostics without making diagnoses?

    Or providing advise under consultation for "maintaining homeostasis", without treating?
     
  29. rmh149

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    Keep in mind, we are not the admitting physician.
     
  30. The_Sensei

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    My thoughts are as follows:

    1) I don't know how you get away with what you just described above- those physicians, if they actually DO exist, who are relying on the judgement of a CRNA with half the training of an anesthesiologist are idiots at best and a disgrace to the profession at worst

    2) I wouldn't send my dog to a hospital where a CRNA has so much autonomy; again if this actually DOES happen; if so....man oh man.......

    3) take your thinly disguised "aw-shucks-just-trying-to-offer-another-viewpoint" crap outta' here - no one wants to hear it
     
  31. powermd

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    Your point of view seems to be one or more of the following:

    1) doctors are not needed in the practice of medicine,
    2) anesthesia and critical care is not medicine, thus no doctor is needed,
    3) anesthesiologists aren't 'real' doctors, the way your surgeons are.

    How can you enter a physician forum, make/imply any or all of these claims, and expect us to believe you're not trying to piss us off?

    You also claim to take responsibility for everything you do- great! No one cares though, because if a physician hands you work to do- he/she is responsible for your actions. You do make it sound like you diagnose and treat all by yourself at times, but if a physician asks you to do it, you're really not independant.

    And by the way, the fact that your surgeons are so happy to defer to you on medical issues will impress NO ONE around here. It is well known to every anesthesiologist how seriously most surgeons take "medical clearance" (just another obstacle between them and the OR). The fact that they trust a nurse to provide a full medical evaluation of their patient, and take legal responsiblity for it by not having a physican do the evaluation speaks volumes about their understanding of medicine, and how little they care.

    A 99th-percentile CRNA can do most of what you say you do successfully most of the time. But what about the rest of your profession- the meat of the bell curve? Should they be allowed unsupervised practice? If you allow it for one, you have to allow it for all. I have met plenty of CRNAs in the short course of my training that can barely chart vitals correctly, let alone give a slick anesthetic, and even less- interpret complex diagnostics in the CC setting. It would be a real tragedy to cut these people loose on unsuspecting patients. Can we at least agree that not ALL CRNAs are fit for independant practice?
     
  32. rmh149

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    PowerMD,

    I do agree that not all CRNA's are capable of independent practice. I have worked with CRNA's that prefer to have a supervising anesthesiologist (like in large teaching hospitals). I have worked withe some older CRNA's that have not had any training in regional anesthesia. Some CRNA's are content to be just technicians. However, that shouldnt mean that the CRNA's that work independently where aneshesiologists are not available work with one arm tied behind thier back.

    Look, I'm not an a** hole that is trying to say anesthesiologists are not needed. There are many things that anesthesiologists do that we cant. But as far as anesthesia is concerned, it is in our scope of practice to do anything related to anesthesia.

    The only thing I am asking is to NOT believe that a physician is required to sign behind or co-sign anything a CRNA does related to anesthesia. Most hospitals in big cities require it and thats their choice. But its not required. Also, it doesnt mean that the surgeon is taking extra risks for using a CRNA.
     
  33. rmh149

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  34. rmh149

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    Very good questions Darwin. The point I was trying to make with the 12L EKG statement is that we are not idiots. We can interpret data...contrary to an earlier statement someone made that we are just technicians.

    Everything we do for the patients has to have something to do with the anesthetic. Obviously it wouldn’t be appropriate for a CRNA to order and interpret an EKG or x-ray on a patient that is not pre or post operative. That of course would be practicing medicine. However, we do order and interpret diagnostics that is related to providing a safe anesthetic and post operative stability. Any other situation is just a suggestion to the physician.

    Example: A 55 y/o obese patient that states that she has to sleep sitting up and frequently experiences swelling in her lower extremities in the mornings. I order a chest x-ray and 12L EKG. It is very likely that this patient suffers from pickwickian syndrome and cor pulmonale related to obstructive sleep apnea and hypoxic pulmonary vasoconstriction. Reasonable right? These are probable diagnosis that may effect her anesthetic....but I don’t diagnose them officially. I do take this information into consideration when performing the anesthetic. I consult a physician to evaluate her and let him/her make the official diagnosis and method of treatment.



    If the patient did not receive an anesthetic from myself or one of my partners, then any advice I provide is strictly a suggestion (hell, ICU nurses do this for docs all the time). However, if this patient is post operative, then we do whatever it takes to maintain homeostasis. If we do the anesthetic....we own it for at least two days.
     
  35. johankriek

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    You are delusional. absolutely delusional.


    anything a crna does in the OR, a physician is responsible for just remember that. If you look at an EKG and in your experience as a nurse clear the patient you think thats ok you are delusional.

    and surgeons who use crnas exclusively ARE Taking extra risks for not having anesthesiologist consultation. What would you think about a hospital who allowed me to perform bowel surgery. Its allowed. The hospitals dont let me because they know there are people who are more qualified namely general surgeons..
     
  36. rmh149

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    Of course! If I look at an EKG that is in the chart of my patient, I may or may not clear the patient to receive an anesthetic. It is my choice based on my judgment. If I think they EKG looks fine, we proceed. If there is a problem, then I cancel the procedure until the patient is properly worked up and cleared by a cardiologist. YES! With my education and experience as a nurse anesthetist, I am capable of reading a 12L EKG and determining clearance for anesthesia.

    You are wrong. Physicians are not responsible for what I do as a licensed anesthetist. Why do you still believe that the captain of the ship doctrine lives? You say that surgeons are taking extra risks. Interesting, the numbers and research (by MD's) state differently.

    For your knowledge, I have listed a link that gives you a better picture of the scope of practice for a CRNA.



    http://www.aana.com/resources.aspx?ucNavMenu_TSMenuTargetID=51&ucNavMenu_TSMenuTargetType=4&ucNavMenu_TSMenuID=6&id=783
     
  37. SleepIsGood

    SleepIsGood Support the ASA !
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    RMH

    Please post on here what hospital with city and state that you are practicing in. Unless you can give us this info and we can verify that you are practicing by yourself...I'm going to have to call you out on this 'bluff'.

    Also to all non-believers that CRNAs are ok and they dont want to step on toes...read this guy's/gal's posts and see for yourself about the fact that CRNAs WANT to take YOUR job as an anesthesiologist.
    :thumbup:
     
  38. rmh149

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    Thats safe..... :cool: How about not.

    No, not trying to take your job. There is plenty for both of us. I just dont want to work with someone looking over my shoulder constantly. I had plenty of that as a student. I enjoy my practice the way it is....even if the laws dont change.
     
  39. johankriek

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    that is easy to remedy. GO TO MEDICAL SCHOOL YOU LAZY SACK OF (expletive). then you wont have anybody looking over your shoulder.
     
  40. rmh149

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    I shouldnt respond to such an unprofessional post....

    My reason for not going to medical school.... I joined the US Army when I was 17. My parents didnt have a dime to send me to school because I was the third kid. In fact, all my college money went to my step brother (whole other story).

    Anyway, at 17 I was a medic. After AIT they sent me to pharmacy tech school. My grades were good there and at the time (Bush senior was in office) they needed nurses. I dont turn down education or the chance to serve as an officer for our great nation. So they gave me a 4 year ROTC scholarship to nursing school. After graduation I served with the 28th CSH airborne supporting the 82nd at Fort Bragg, NC. Soon afterwards Bill Clinton drew the forces down. Thankfully while I was there they paid for me to get my Master in Health Service administration degree. A few years later as a civilian the Army still needed anesthesia providers.....so I jumped on the oportunity and went to anesthesia school with the ARMY's help and signed on for another 6 years of service. I sold the house, took the dog, two kids and wife and went to school. It was a big risk and almost lost my family...but I still believe it was worth it.

    Medical school would have been nice but at the time the ARMY wasnt sending too many people. I went where the opportunities were. I thank the American taxpayers and the Army for providing me the means to acquire a BSN, MSA, and MSN...in exchange for my military service and willingness to defend your right to call me a lazy sack of (expletive). I am honored to do so.

    I do respect you for attending and completing medical school and residency (if you are done). However, the hospital and inviting physicians where I am credentialed and practice was impressed enough with my CV to allow me to practice independently. Trust me when I say that I respect this privilage.

    I assure you sir, I am far from lazy.
     
  41. jeesapeesa

    jeesapeesa anesthesiologist southern california
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    It just seems like you're here to stir up trouble. You know well enough that this is a premed, med student, resident, attending forum and your comments will provide fuel to the already strong feelings against the AANA and its propaganda in this forum. Anybody can join and comment here, but if you're smart you will realize that comments like those can be expected if you just continue to press your points.
     
  42. powermd

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    The anesthesia care team model protects your job by keeping anesthesia a physican-based specialty. Your current salary level depends on physician involvement in anesthesia. If your comrads succeed in convincing policymakers that "anesthesia is nursing", private pay reimbursements will start to reflect that. Medicare/Medicaid rates are already there. CRNA schools continue to pump out graduates that will continue to depress salaries. The end result will be pretty close to what you'd make as an APN in any other field.

    Having someone look over your shoulder every now and then is a small price to pay in ego for an extra 75K/yr. It may even benefit patients, what a concept!
     
  43. rmh149

    2+ Year Member

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    Strong point...and well taken.
     
  44. johankriek

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    dude

    save me and everyone else on this board your story. There are many people on this board whose story is more humble yet they completed medical school . You are desperately looking for approval on this board. You want to be somebody. you wanna be accepted. Listen let me help you out. I dont care about you or your sob story or how many masters degree you have. or how good you can diagnose dehydration. You are a nurse. no matter how many paragraphs you write to say the contrary, at the end of the day you are a nurse.. Look yourself in the mirror, get a therapist, and learn to accept this.
     
  45. The_Sensei

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    :thumbup:
     
  46. BlackScorpion

    BlackScorpion Member
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    Best reply ever. Let me share my sob story. Father died when I was a freshman in undergrad. Decided to go to med school after that. Took HPSP scholarship for med school, so my mother doesn't have to pay for school. Don't believe in short cuts. Now deferred for anesthesiology residency in a civilian progrram. Hate midlevel providers who thinks that they are the only fu*kers who had it rough. Don't believe that anyone owes me anything. Busted my ass this far so I can be a physician with all it's privilleges.

    Save me the the oh, I am special because I am non-traditional. If you wanted to you could have gone to med school. Kills me to see CRNAs trying to obtain independent practice through legislation instead of EDUCATION.
     
  47. rmh149

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    Morons...its not a sob story. I just went the ARMY route instead of Med school route. I was just defending the "lazy sack of (expletive)" comment.

    I'm not complaining...I had a great time and still have a great life.

    Sorry about your dad.
     
  48. cfdavid

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    Gents,

    RMH is nowhere near the antagonist that good ole nurse nitecap was. Let's give him the benefit of the doubt until it gets really bad. There's no harm in listening, as long as it remains somewhat professional. At least the dude can put sentences together.

    RMH, the reason that the tolerance level is such that it is, is because for years, SRNAs (mostly) have come over to antagonize (no better word hence I repeat it over and over) us with their rhetoric. I've personally experienced this, and it was very annoying to say the least.

    This is a forum designed for pre-meds, med students, residents, and attendings. We come here to share ideas and to blow off some steam. It's a support network and an open forum to hang with others of SIMILAR professional goals. It's really not meant for nurses. So, if you keep gettting abused, it's really not personal so much as it is just the same old hat that many have experienced for years.
     
  49. rmh149

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    I totally understand. I dont blame and MD/DO for their stand against the AANA. I also dont blame any CRNA for standing behind the AANA. I think I am going to just stand in the background and watch what happens.

    Reading the posts here really has given me some insight though. Its easy to have an opinion if all you read is one side. Reading this forum has prompted me to do more research and look at the issues from both sides...with an open mind. Believe it or not...as much as I wanted to avoid MDA/DO's to practice independently, I'm sure it would still be wonderful. I am seriously looking into doing some time with my brothers group (ACT model) to get into some bigger cases.
     
  50. zippy2u

    zippy2u Senior Member
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    Well now, sure haven't heard many sob stories lately, prolly since the repubs are in office. Get your sob stories polished up soon because ya gonna hear a lot of em when the Dems get back in town-- everybody and their mamma gonna be wantin' that gov hand out. Yeah, ya gonna have another Clinton in that White House shortly. Regards, ----Zippy
     
  51. rmh149

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    Havy faith in Rudy!
     

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