contact with CRNA's

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I am curious as to all of your experiences with CRNA's. how is the work enviornment with them, and their competency in your actual contact experience.

 

[Skip Intro]

I am curious as to all of your experiences with CRNA's. how is the work enviornment with them, and their competency in your actual contact experience.

It varies, of course, by the person. In the last four weeks, I worked with about 7 different attendings (6 MDs and one DO), 4 CRNA's, and one AA. The CRNA's varied from one who had 20 years experience (and knew as much about giving gas, if not more, than some of the more junior attendings) to another who was just out of school and was carefully supervised during her cases (and, I actually taught her a trick with starting IVs that she had not been shown before... so learning can be a two-way street, even if you are simply a lowly medical student). Nonetheless, I learned a lot from each of them. Everyone had slightly different preferences and ways of doing things. But, the care that every patient I saw on the 100 or so cases I observed/participated in was excellent. It truly was a team approach, which is the way medicine should be done no matter where you are.

Having said all of that, I personally - and this is JUST my observation - think that the CRNAs were essentially great technicians whereas the MDs/DO were a little better at trouble-shooting and thinking through problems. The CRNAs are "taught" how to give anesthesia and were more "by the book" than the MDs/DO were, and because of this the CRNAs do it extremely well. The difference I saw was that the MDs understood the pharmacology and the "art" of anesthesia much better than the CRNAs. For example, one of the more seasoned CRNAs started to lecture me about not giving beta-blockers to asthmatics. Was she wrong? Well, of course not if you read the textbooks. The difference was, as even myself beginning my fourth year of medical school, that if you have a better grasp of the pharmacology, you know that certain beta-blockers are not absolutely contra-indicated in asthmatics. The point is, I have sufficient training in and understanding of autonomic physiology to explain why; she did not. She had simply been "taught" long ago not to give beta-blockers to asthmatics - and that's as far as her knowledge goes.

That's really the difference. I have no doubt that CRNAs can give anesthesia technically as well as an MD or DO. But, the breadth and depth of our basic training (pharmacology, physiology, pathology) is much greater than a CRNA's and, yes, this can prove to be extremely important during difficult cases.

In my first experience, I would conclude that CRNAs are every bit as good as an MD/DO at teaching the technical aspects of anesthesia, but I would not rely on them to learn the "medicine" (e.g., pharmacology, physiology, etc.) and "art" of anesthesia. In most cases, it seems to be simply beyond their scope of training and, frankly, level of interest as well.

-Skip

P.S. I forgot to mention the one AA. His job was really limited to being an extra pair of hands and someone to set-up and break-down the circuits before and after each case. He did not "run" any cases and/or do any procedures, push drugs, etc.

 

[gasnurse]

let me enter this thread on the behalf of crnas. to begin with....we learn anesthesia from the same textbooks that you all do....miller, "god of anesthesia", cousins, barash, etc. i'm sorry, i must have missed that there was a separate edition for crnas. in the past i have worked "supervised without supervision" meaning the MD signed the charts in the AM for the day, went to the call room to watch movies and we did the cases. not bread and butter only but also AAA's, etc. i've also worked under "supervision" for a private practice group who knew i was safe, vigilant and well educated. it was as independent as it can be being "supervised". i now practice independently (no supervision requirement from surgeon, either) billing on my own doing ent and plastics. i also work with a group of crnas in a very busy OB with over 500 deliveries a month. how is it possible that things have gone well for so many years in such a high risk environment as OB without MD's around??? i'll tell you....we are a well educated, safe group of practitioners. yes, there are bad crnas and good crnas and the same goes for MDs. anyone who thinks they are perfect are a liability waiting to happen. am i safe? yes. am i well educated? yes. could have i have gone to medical school if i wanted? most likely. i chose not to. i don't want to be a doctor, i'm a nurse. i have no problems working with docs and they have no problem working with me. i think it would do us all a world of good if we could stop bickering and get along. neither one of us are going away nor could we with the market demand. get over who knows what and why and know that there are crnas and docs on both ends of the spectrum. i think it's best to have an open mind and judge for yourself when working with various anesthesia providers. you may be surprised what you conclude. and as far as that beta blocker/asthmatic scenario don't act as though crnas don't know beta1 drugs are safe to use. come on, i worked cardiac/transplant/pediatric ICU for 8 years and know a lot about pharmacology and trouble shooting. i've also read on this site somewhere how crnas can't think "outside the box". give me a break. perhaps it makes you feel better to feel you are superior. whatever you all need.

 

[antiadriani]

For example, one of the more seasoned CRNAs started to lecture me about not giving beta-blockers to asthmatics. Was she wrong? Well, of course not if you read the textbooks. The difference was, as even myself beginning my fourth year of medical school, that if you have a better grasp of the pharmacology, you know that certain beta-blockers are not absolutely contra-indicated in asthmatics. The point is, I have sufficient training in and understanding of autonomic physiology to explain why; she did not. She had simply been "taught" long ago not to give beta-blockers to asthmatics - and that's as far as her knowledge goes.


-Skip.

Skip...please remember that the training of CRNAs begins outside of the book in the intensive care environment. It is a requirement that we appreciate the value of clinical education before we receive our didactic training (even though we are working as professionals). I think that all of us would agree comparing our educations is an apples and oranges thing. Your point would be more persuasive with non-anecdotal experiences.

Maybe it might be more persuasive if you generalized medical training by showing us the standards for accredited medical training in pharmacology. I know what the schools are estimating/ reporting but these are not standards...http://services.aamc.org/currdir/section4/start.cfm.

I know as a first year srna that the aana mandates at least 105 hours of pharmacology.

Funny you mention the beta blocker selectivity / asthmatic thing. We had a test question on that grey area last week. You and I as students realize these hair splitting principles, but later when we begin our practice, a lot of this information will start collecting dust on a back shelf in our memory, and we may even forget...oh well. Even if the crna that tried to correct you may have been condescending (its healthcare culture), he /or she hopefully went home and looked it up.

Anyway, thank you for keeping your comment civil. It is refreshing to come to these forums and see objectivity, even with a few anecdotes. I may be in the crna's shoes one day, and it is good for me to see how I might handle these situations later.

 

[jwk]

P.S. I forgot to mention the one AA. His job was really limited to being an extra pair of hands and someone to set-up and break-down the circuits before and after each case. He did not "run" any cases and/or do any procedures, push drugs, etc.

Skippy, what you are describing is an Anesthesia Tech, not an Anesthesiologist Assistant. There's a big difference. Try and get your labels correct. If it in fact was an AA (which I sincerely doubt) they're probably only there while a spouse is in residency or med school and just biding their time.

AA's are not licensed in New York, so you won't find any practicing there at present. However, there used to be an AA at Mount Sinai several years ago, with either an Assistant or Associate Professor academic rank.

 

[Mr_Money]

perhaps it makes you feel better to feel you are superior. whatever you all need.

Well, dear...........that's because we are!! 🙂

 

[gasnurse]

Well, dear...........that's because we are!! 🙂

that attitude gets you nowhere....you're one of the reasons there is such a problem between anesthesia providers. why don't you grow up!

 

[cyclicamp]

GasNurse,

Have you elevated CRNAs to the status of MDAs? I do understand that CRNAs have advanced training and learn principles of pharmacology and physiology. However, you seem to insinuate that when all is said and done the end product from both camps is comparable (maybe so.....maybe I have truly wasted many years on my education)? So, please tell me in your most honest opinion what the actual difference is between the two?

 

[NaeBlis]

Wow, it looks like this thread has gotten at least 3 people to open accounts to post here. 🙂

 

[gasnurse]

GasNurse,

Have you elevated CRNAs to the status of MDAs? I do understand that CRNAs have advanced training and learn principles of pharmacology and physiology. However, you seem to insinuate that when all is said and done the end product from both camps is comparable (maybe so.....maybe I have truly wasted many years on my education)? So, please tell me in your most honest opinion what the actual difference is between the two?

thank you for your mature discussion. like i said in my first post to this thread, i am a nurse, not a doctor. i will never claim to be a doctor. i give anesthesia as a crna. crna training is extensive contrary to what most want to believe. instead of coming in to training out of medical school we come in to it out of hands on clinical experience, most of us from an ICU setting. i think that experience is invaluable. we study from the same texts, administer the same drugs and do the same types of anesthesia for cases. there are many places in the country where anesthesia is given by crnas without any md input. like i stated before, i am one of those individuals along with several of my colleagues. we manage high risk OB patients every day. things have gone smoothly for many years. when i give anesthesia solo i bill for my services and get reimbursed as the mds do. so are we the same??? there are good and bad of both, extremely smart in both groups and some you wonder how they ever got through their program. we can all make mistakes or be involved in a bad outcome. obviously crnas and mds are comparable to some degree or there never would have been an opt out or supervision requirement change in the first place. not being a doctor myself i'm not sure if there's some "special" anesthesia knowledge you all were taught that i wasn't. perhaps. i just don't feel it's fair for some to judge a crna that we can't think on our toes or go beyond the book. even an icu nurse has saved the butt of many a resident by thinking ahead. so to try and answer the question, the difference is you are an md and i'm a crna. you went to medical school and i didn't. am i as "smart" as you? am i "clinically" better than you? do you know something i don't? i think that all varies. i don't think you are wasting your time. you've gone in to a great field. you will have many job opportunities in many different types of practice. you will make a good living and hopefully enjoy what you are doing. i value my relationship with the mds i have worked with in the past and would welcome that relationship again. we all contribute something to the team.

 

[Mr_Money]

we all contribute something to the team.

You sure do..........now go start that cataract extraction in OR 23 while I watch movies in the physicians lounge!

 

[cyclicamp]

Gasnurse,

First of all, let me say something. For anyone to state that a nurse does not typically think outside of the box is a *****. Like you said, there are good and bad in all professions. I love nurses, my mother is a nurse and she saved my life when I was in the hospital and had complications due to surgery...the lovely intern thought his limited education could compare to my mother's 20 + years of clinical experience.....that is the hieght of pomposity. However, there must be a difference between a seasoned nurse practitioner and a seasoned doctor....or else what is truly the difference between a nurse practitioner or pediatrician, a CRNA or MDA, Nurse midwife or OB-gyn? I guess I just feel lost and want to know what the tangible differences are? If there really aren't any then what is wrong with our medical education system? See what I am saying? Geez, if my biochemistry, pharmacology, pathology, micro, phys somehow is going to make me that much sharper, I feel bad for my future patients because, although I do well in school and on exams, I forget half of that crap in a couple of weeks.......and so do most students. I guess I am at one of those points in my life where I feel as though I have spent much money on an education that is not needed to get the job done. 🙁 Any thoughts would be greatly appreciated.

 

[powermd]

You sure do..........now go start that cataract extraction in OR 23 while I watch movies in the physicians lounge!

I love watching threads like this degenerate. I think it's obvious that the presence of CRNAs who are pretty much identical in ability to MDs hurts feelings and crushes egos on the MD side. Think about it- you spend 8 years in school, 4 years in residency, $120K+ in med school tuition, only to find out a nurse can do your job about as well as you. That hurts. I'm an intern going into anesthesiology, and I'd like to think what I bring to the table as an MD is valuable, and maybe it will be at times, but on most days it probably won't. What I'll bring to the OR is clinical experience no different from that of well-trained CRNAs. I'd like if, when I graduate, I could earn the salary I expect to, without feeling just a little bit guilty that a CRNA will do exactly the same job (albeit 'supervised') while getting paid half. I'd like to think that being an MD I bring so much more to the table that I am worth twice as much as a CRNA. But maybe I'm not. I don't know anymore.

Maybe it's not so much a CRNA vs MD thing, but a person vs person thing. Some people are smart, and can think on their feet, and will succeed regardless of how they enter a field. Others will do less well. Maybe that's the real difference. Maybe you're more likely to find those capable people on the MD side than the CRNA side. Just a few thoughts.

 

[gasnurse]

cyclicamp and powermd,

thank you for your comments. i appreciate that you have an open mind and because of that you will do well in the profession. good luck to both of you with your training and future careers.

 

[tkim]

You sure do..........now go start that cataract extraction in OR 23 while I watch movies in the physicians lounge!

Comments like these are not productive and not welcome. Keep it civil.

 

[sones]

Thank you so much for your open mind. Thank God there are people out there like you who can express their opinions without getting rude about it. There is no reason for bashing each others professions. I am a little new to this anesthesia debate, being a first year SRNA. I think CRNAs can practice anesthesia very well most of the time. There are definitely those times where I thank my lucky stars I have a staff anesthesiologist right there! I know the CRNAs at my clinical sites are very glad for the same thing. I don't think anesthesiologists are probably paid as well as they deserve sometimes, I don't know what to blame that on, I"m not sure that CRNAs are the correct scapegoat...they may be...I don't know. Medicare and medicaid just can't pay anymore...insurance companies won't pay. No money, no salary. The reality of the situation is there is a huge demand for anesthesia providers, MDA, CRNA, AA. There is no lack of jobs posted....look on gaswork.com. I think it's too bad MDAs have $100,000-$200,000 worth of debt. I think that is terrible!! I can't imagine trying to pay that off, especially when most are at least 30+ when they actually get out of residency and are trying/continuing to raise families and get somewhere past an apartment and ramen noodles for supper. I understand that doctor's egos get crushed when a nurse can perform the same job...but is it the same job? CRNAs don't run critical care units, CRNAs don't generally do chronic pain mangement (at least not that I have heard of). There is a definite need for MDAs, but there is definite need for CRNAs. We nurse anesthesia providers get very offended when some residents, medical students, MDAs, DOS, whoever, insult us and tell us we have no right to be practice anesthesia. There is a place for us...infact, there are probably 4 different places for each of us graduating. Maybe well all should go back to kindergarden and learn how to get along, this is just ridiculous. Isn't the patient the one we should be concerned about...there really are the reason we are there...not our egos, money or anything else...if that's not why your in healthcare..I think the wrong career might have been selected. 😛

 

[sones]

Comments like these are not productive and not welcome. Keep it civil.

YOu are so right and thank you for saying something!!! 👍

 

[sones]

Gasnurse,

First of all, let me say something. For anyone to state that a nurse does not typically think outside of the box is a *****. Like you said, there are good and bad in all professions. I love nurses, my mother is a nurse and she saved my life when I was in the hospital and had complications due to surgery...the lovely intern thought his limited education could compare to my mother's 20 + years of clinical experience.....that is the hieght of pomposity. However, there must be a difference between a seasoned nurse practitioner and a seasoned doctor....or else what is truly the difference between a nurse practitioner or pediatrician, a CRNA or MDA, Nurse midwife or OB-gyn? I guess I just feel lost and want to know what the tangible differences are? If there really aren't any then what is wrong with our medical education system? See what I am saying? Geez, if my biochemistry, pharmacology, pathology, micro, phys somehow is going to make me that much sharper, I feel bad for my future patients because, although I do well in school and on exams, I forget half of that crap in a couple of weeks.......and so do most students. I guess I am at one of those points in my life where I feel as though I have spent much money on an education that is not needed to get the job done. 🙁 Any thoughts would be greatly appreciated.

Of course there are differences. MD/DOs are generally much better suited to deal with situations than CRNAs, NPs, CNMs, especially situations that are out-of-the normal. However, there is a place for advanced practice nurses. Doctors cannot handle the volume of cases that coming in to offices, hospitals, etc these days. They need some midlevels to assist. In addition, there are many rural areas where MDs either don't venture or cannot afford to have an MD so they hire an ARNP to provide services. Is this a good idea? Well, if you lived 3 hours from the nearest hospital and you were pregnant would it be necessary for you? For me it would be!! People in the rural areas demand healthcare to be available for many services. It's a mess..but it's realiity!

 

[sones]

Well, dear...........that's because we are!! 🙂

I noticed your name is Mr. Money...is that why you are in medicine? I would suggest you rethink your motivations. I pity your poor patients who come to you for help and all you see is dollar signs.

 

[MacGyver]

Skip Intro,

Even if MDAs KNOW more than CRNAs, it doesnt translate all that often into practical advantages or disadvantages when running gas.

Even if MDAs know 50% more information than a CRNA, thats semantics because the CRNA can actually DO 90% of what an MDA does. Knowledge does not always translate into different clinical outcomes.

MDAs are in trouble long term. The market will not support paying an extra 50-100% in salary to an MDA who can only do 10% more than a CRNA.

MDAs will always have jobs, but lets face it. Eventually insurance companies and Medicare/Medicaid and the federal govt in general are going to realize that they can save a **** load of money by paying MDAs the same rates as CRNAs.

 

[GASCRNA]

I mean no disrespect McGyver but CRNA's can do 100% of what a MDA can do, we have full scope of practice and anesthesia privlidges based on our education and training as well as hospital privlidges. Thank you GasNurse for all your wise and informative opinions ! Where is Tenesma ?

 

[Mr_Money]

I mean no disrespect McGyver but CRNA's can do 100% of what a MDA can do:

No you cannot! To name just A FEW things CRNAs cannot do: run an ICU, do chronic pain management, perform blocks under fluroscopic guidance, write prescriptions............. 😀

 

[Tenesma]

oh really... you can do 100% of what an MDA can do...
so that must mean you can:

1) become director of a PACU
2) provide ICU back-up coverage in community hospitals
3) do an 11 hour old 32 weeker premie for a bilateral craniotomy for Grady IV bleeds from forceps delivery (who by the way has a right to left shunt)
4) do a lung transplant
5) do a liver transplant and manage CVVH at the same time on a hepato-renal syndrome patient
6) do an elective thoraco-abdominal aneurysm repair w/ spinal cooling and lumbar drain
7) provide critical care management in the OR for intra-operative catastrophes ....

and the list goes on...

knowledge doesn't lead to different clinical outcomes???? are you kidding me?... MacGyver, while I agree with most of your postings about the increasing presence of midlevel providers, you can't be serious about the above quote... The whole point of gaining more knowledge is to create an environment for better clinical outcomes. Just look at a graduating CRNA who will have a total of 1600 Clinical Hours vs a graduating MDA who will have a total of 10,000 clinical hours (and that doesn't include the 4000 clinical hours during internship). Who do you think will have a higher success w/ their thoracic epidurals? Who do you think will have a deeper understanding of the variety of odd medical diseases...

And you keep on saying the market won't support higher salaries.... why are my colleagues getting 300-350k/year working in states that have opted-out of physician supervision for CRNAs... In fact, despite the increasing strength of the AANA we have yet to see a dip in the salaries of MDAs - if anything they continue to be as strong as ever... and as far as insurances paying MDAs and CRNAs the same... guess what??? they already do in many areas... i think medicare still only reimburses 85% for unsupervised CRNAs though (so still not perfectly equivalent).

anesthesia gets reimbursed based on units, the reason MDAs make more, is that the more complicated cases get more units...
1 unit =15 minutes (simplified explanation) ...a thoracic epidural is 7 units, an a-line is 1-2 units, etc... you can see how the bigger the case, the more complicated the monitoring , the more money can be charged based on units, plus time spent on the case.

as far as high-risk OB goes.... there is high-risk and there is HIGH_RISK... believe me, no HIGH_RISK OB is going to be at an all-CRNA hospital.

 

[Mr_Money]

Keep preachin' to the flock..........we shall overcome!! 😍

 

[Zeffer]

I did an Ovid search today and found this to be an interesting article. Hope those of you with access to this journal enjoy reading it. I have many friends applying to anesthesia this year and wish all those who do the best of luck with their futures.

Abenstein JP. Long KH. McGlinch BP. Dietz NM. Is physician anesthesia cost-effective?. Anesthesia & Analgesia. 98(3):750-7, table of contents, 2004 Mar

 

[Gator05]

Amongst many issues inherent to this debate is the issue of education. About a year ago, was lucky enough to enjoy a talk by our University President on the role of education in professional networks. We can apply the same concepts to anesthesiology.

Briefly, and educational institution functions much like a guild. They educate you toward a certain end. At the conclusion of the particular phase of education, they certify that you have met the objectives of the particular educational endeavor. This repeats on a variety of scales, culminating in graduation/course completion/passing an exam. Ultimately, the educators must place their "seal of approval" on their students, certifying to the pertinent communities that the student has achieved the goals required by the educational institution in question in order to be granted the title/responsibilities/rights and privileges of said graduate.

When a resident graduates from an anesthesiology residency, the program is in effect saying he is able to handle any and and all situations to be encountered in the perioperative period. Let me repeat; the program director and faculty members are personally attesting to this fact, that EACH and EVERY resident who graduates will be able to handle any and all situations to be encountered in the perioperative period. (By the by, "handle" includes referring to more specialized/advanced care.)

Now some (most?) residents will be ready by CA-2 year to handle most of the situations they will encounter while in an unsupervised environment. In order to satisfy the requirements of the guild/educational institution/ABA, to provide and prove competency in providing for patient care in the perioperative setting , 60-80 hours/week x 48 weeks x 3 years is required for a BASIC level of competency. Remember, we haven't approached the issues and competencies addressed with fellowship training.

How does this pertain to CRNA's? Because not all CRNA's have 10+ years experience; several SRNA's seem to have only 1-2 years, if that. As you remove this "previous healthcare experience" from a person's training, you are left with only the 6 total years of post-high-school, formal education. Tenesema has already touched on previous posts of the minimum number of procedures/cases/hours of CRNA's vs. MDA's.

And so CRNA's are presented with a conundrum. They seek to increase their numbers, but to do so means decreasing the admission requirements. You are left with a product of education which is suddenly questionable; is this graduate truly ready for independent work? Or more appropriate perhaps for supervised work? The guild doesn't get to choose how many years you've been a CRNA, only that each graduate is completely prepared to care for patients.

Again, on their first case post-graduation, each CRNA can be compared with a newly graduated MDA. The MDA's experience is known, as no assumptions are made about "prior healthcare experience". With the CRNA, however, it is a lottery; is this a former CICU nurse with 15+ years experience, or someone who worked only one year after getting a BSN as a floor nurse? Perhaps this person may have been a pharmacist for 2-3 years? Or, worse still, an office worker who decided to sign up for the "advanced-tracks" to become a BSN in ~2 years? Again, the MDA has 10,000+ verifiable hours in anesthesiology training.

 

[Skip Intro]

There are definitely those times where I thank my lucky stars I have a staff anesthesiologist right there!

I think this perfectly sums up my point in this "debate".

-Skip

 

[Skip Intro]

Even if MDAs know 50% more information than a CRNA, thats semantics because the CRNA can actually DO 90% of what an MDA does.

Not now nor have I ever argued against this point. The "other 10%" is why Anesthesiologists exist and will always have a job.

The rest of your post is pure speculation, as per usual, MacGyver.

-Skip

 

[Skip Intro]

I did an Ovid search today and found this to be an interesting article. Hope those of you with access to this journal enjoy reading it. I have many friends applying to anesthesia this year and wish all those who do the best of luck with their futures.

Abenstein JP. Long KH. McGlinch BP. Dietz NM. Is physician anesthesia cost-effective?. Anesthesia & Analgesia. 98(3):750-7, table of contents, 2004 Mar

Well, everyone can look at the abstract on PubMed. Here's the link...

http://www.ncbi.nlm.nih.gov/entrez/...ve&db=pubmed&dopt=Abstract&list_uids=14980932

... from which this excerpt is taken:

Recent outcome studies suggest improved patient outcomes when physicians medically direct nurse anesthetists versus anesthesia care delivered with nonmedically directed nurses.

I think, again, that pretty much sums up and corroborates (non-anecdotally, I might add) my observations in the 'real world', thank you very much.

-Skip

 

[Skip Intro]

In fact, here's a link to a whole bunch of abstracts the majority of which essentially conclude, in one way or another, that anesthesiologists (MDAs) will continue to be needed, strong collaborations should be fostered between MDAs and CRNAs along with recognition of the differences in training and level of responsibilities, and an inferred general conclusion that CRNAs should not, as a standing rule, be given licensures to practice alone:

http://www.ncbi.nlm.nih.gov/entrez/...=Display&dopt=pubmed_pubmed&from_uid=10702442

-Skip

 

[MacGyver]

In fact, here's a link to a whole bunch of abstracts the majority of which essentially conclude, in one way or another, that anesthesiologists (MDAs) will continue to be needed, strong collaborations should be fostered between MDAs and CRNAs along with recognition of the differences in training and level of responsibilities, and an inferred general conclusion that CRNAs should not, as a standing rule, be given licensures to practice alone:

http://www.ncbi.nlm.nih.gov/entrez/...=Display&dopt=pubmed_pubmed&from_uid=10702442

-Skip

Too little, too late.

where were these studies when the CRNAs were pushing for independent practice 10 years ago? Once again, the MDAs ignore the threat until its entirely too late. Nearly all states allow CRNAs independent practice with no MDA supervision required.

Now that the scope of practice has been changed in most states, do you REALLY think the states are going to go back and get rid of the changes? Hell no they arent. Once the CRNAs get scope increases, they get it forever and there's no going back.

You need the studies BEFORE THE STATE LEGISLATURES CHANGE THE LAWS. The CRNAs get this and used it to their advantage, while the MDAs waffled around forever and waiting until after all the laws had been changed before they decided to put out their own studies. I dont care if you've got 1000 studies showing that CRNAs suck, it wont matter after the laws have already been changed.

Like I said, too little too late.

 

[MacGyver]

Not now nor have I ever argued against this point. The "other 10%" is why Anesthesiologists exist and will always have a job.

I NEVER said MDAs wont be able to get a job. What I DID say is that the market wont support paying an extra 50% income to a person who can only do 10% more than a less "expensive" individual can do.

I dont understand the constant mantra on this forum that "MDAs will always get to direct the 10% most complex cases." Thats entirely moot and irrelevant to the profession at large. By adhering to this logic, MDAs will pigeon-hole themselves into a small corner of the market, and lose any influence they currently have other nationwide anesthesia policy.

If CRNAs control 90% of the gas market (they currently control about 60-70%) what the HELL do you think thats going to do to future lobbying efforts? If CRNAs control 90% of the gas market, their voice is going to be the ONLY one heard or listened to in state legislatures and Congress.

When and if government believes that MDAs are really only necessary to direct 10% of the gas given in the states, thats going to be the end of anesthesia as a specialty as we currently know it. It wont be an option for the vast majority of future med school grads, residency slots will be slashed (why would the government outlay billions of dollars for residency slots when MDAs can only do 10% more than a CRNA?), and gas will become a minor residency/fellowship thats only open to a few med school grads every year.

Of course, like most MDAs, you probably dont give a damn about the long term future of gas. You just want to make money and cash out I assume. Thats the whole reason gas got into this mess to begin with. A bunch of greedy MDAs figured "hey lets train CRNAs and bill for their procedures." Of course, they didnt care that they opened pandora's box and that CRNAs would not consent to be the MDAs slaves forever. But why do they care? They've already retired with their millions. They've "cashed out" and dont give a **** what happens to gas 30 years down the line.

 

[Tenesma]

MacGyver...

before you start throwing out numbers, i suggest you do some research

1) there are 35,000 practicing anesthesiologists and there are 32,000 practicing CRNAs... so how do they control 70% of the market? Are you falsely elevating the current AANA statement that "60% of anesthetics are provided by CRNAs"??? that statement is slightly misleading since 85% of those anesthetics are actually medically supervised by anesthesiologists.
And how will CRNAs control 90% of the market when in fact, MD programs graduate about 1200 residents/year and CRNA programs graduate about 900CRNAs/year... so your numbers don't add up... the only way your numbers could ever add up is IF: MD programs cut their residency spots and CRNAs increase their output... Neither of which is going to happen ANY time soon.

2) "there is no way the job market can support the number of MDAs graduating": again, you have no sense of what the literature shows (and I am quoting from the Mayo Clinical Proceedings 2003, the Cleveland Clinic Study 2002 and the Medicare reviews of 2000 and 2001). In fact, all three of those reviews/studies show that there will be a shortage of 3000-4,500 MD Anesthesiologists by 2005 and double that shortage by 2015. And the estimated retirement rate is currently 300/year and is expected to be 800/year by 2010.

3) and CRNAs won't be able to take advantage of the glut of anesthesiologists for two reasons A) the huge shortage of people going into nursing (which is a pre-requisite to become a CRNA) B) the unwillingness of CRNA programs to expand or multiply due to the advantages of the current and future supply/demand issues.

so MacGyver - either you start posting realistic numbers and continue to provide arguments based on research and studies, or you can continue to be viewed as a cook who likes to spread fear and is not to be respected (or put on ignore lists).

(Base units + Time units + Modifying units) x $ Conversion Factor = Anesthesia Charge
AND!!!! further more, you obviously ignore my posting about reimbursement rates that explain why MDAs make more than CRNAs!!!!
If i do a thoraco-abdominal esophagectomy on a patient w/ severe MR and and EF of 15%, i get 7 units for a thoracic epidural, 3 units for an a-line, 10 units for a Swan-Ganz catheter, requires massive blood transfusion 10 units, and the case goes on for 11 hours, which is 11x4=44 Units... so without conversion factors that is 74 units for a days of work... so if you are getting reimbursed by medicare it would be about 35$/unit which is about 2600 for a day of work, or if it is blue cross blue shield in michigan it would be 63$/unit which is about 4600 for a day of work. So the only way that a CRNA can make the same amount of crazy money an MDA can make, is to for a CRNA to do on a regular basis these kinds of cases - which just doesn't happen... and won't happen as long as Surgeons request MDAs for big cases, as long as Anesthesia Residencies are at the big teaching hospitals where cases like these happen, and as long as more MDAs graduate every year then CRNAs...

so MacGyver, again, bite me...

 

[Mr_Money]

so MacGyver, again, bite me...

Whoa! What a post! My hero!!! 😍 😍 😍 😍

 

[Skip Intro]

If CRNAs control 90% of the gas market (they currently control about 60-70%) what the HELL do you think thats going to do to future lobbying efforts? If CRNAs control 90% of the gas market, their voice is going to be the ONLY one heard or listened to in state legislatures and Congress.

Where do you get this fearmongering stuff?!?? Do you just make it up? You have such an alarmist imagination and penchant for creative license I'm starting to think you should give up medicine and be a paperback fiction writer.



-Skip

 

[MacGyver]

(Base units + Time units + Modifying units) x $ Conversion Factor = Anesthesia Charge
AND!!!! further more, you obviously ignore my posting about reimbursement rates that explain why MDAs make more than CRNAs!!!!
If i do a thoraco-abdominal esophagectomy on a patient w/ severe MR and and EF of 15%, i get 7 units for a thoracic epidural, 3 units for an a-line, 10 units for a Swan-Ganz catheter, requires massive blood transfusion 10 units, and the case goes on for 11 hours, which is 11x4=44 Units... so without conversion factors that is 74 units for a days of work... so if you are getting reimbursed by medicare it would be about 35$/unit which is about 2600 for a day of work, or if it is blue cross blue shield in michigan it would be 63$/unit which is about 4600 for a day of work. So the only way that a CRNA can make the same amount of crazy money an MDA can make, is to for a CRNA to do on a regular basis these kinds of cases - which just doesn't happen... and won't happen as long as Surgeons request MDAs for big cases, as long as Anesthesia Residencies are at the big teaching hospitals where cases like these happen, and as long as more MDAs graduate every year then CRNAs...

I responded to the other part of your post in the other thread.

As for this, let me state again that this is IRRELEVANT! Who cares if the MDAs get to do 10% of cases that are too "complex" for CRNAs to do. That doenst benefit MDAs at large, it only benefits the "superstar" MDAs who work at large academic medical centers. The rest of the MDA group will be left out in the wind.

for one thing, you assume that CRNAs will never increase their scope of practice to do these complex procedures. Thats an incredibly dubious assumption. But I'll leave that for another day.

Even if you are RIGHT and CRNAs agree to a law which says that they are restricted from doing the 10% cases, thats still a pyrrhic victory for MDAs.

Sure, the MDAs that actually do those 10% of cases might make more money than the CRNAs, but the MAJORITY OF MDAs which DONT do those kinds of procedures often are going to see their salaries plummet.

The average CRNA income is a little over 100k. This comes straight from the AANA website. In contrast, the MDA average is well over 200k. The ONLY REASONS why MDAs are still making more money right now is:

1) MDAs can bill for "supervising" CRNAs, whereas CRNAs cant do the same.

2) MDAs participate in the "10%" group of complex procedures that reimburse more than the vanilla "90%" group of procedures that MDAs and CRNAs share.

3) MDAs are reimbursed an extra 15% for the "90%" group of procedures thats shared by CRNAs and MDAs.

Expect ALL of these things to change in the long term future.

The first thing to change will be the reimbursement for the MDA/CRNA shared procedures. Long term, Medicare is not going to pay MDAs an extra 15% to do the SAME PROCEDURE THAT A CRNA WILL DO. You are crazy if you think thats going to be the case over the long haul. For the 90% of cases which can be done by either MDA or CRNA, the government is going to set the same reimbursement levels for both groups. More specifically, they will reduce the reimbursement for MDAs to match that of CRNAs. After all, the only other alternatvie is to raise CRNA reimbursement, and government bureaucrats wont let that happen.

Eventually, the government will figure out that they can arbitrarily reduce MDA billing for CRNA-shared procedures to the same levels as the CRNAs. There are government bureaucrats hard at work RIGHT NOW to figure out how to reduce costs. Thats all they do, all day long, is look for ways to reduce spending. So when you sleep in your bed at night, think about them, because they will be thinking about how to screw you over. That is, unless you belong to the magic MDA "10%" group. From your postings, it sounds to me like you think you belong in this group. In that case you are fortunate. But lets be clear: your fellow MDA colleagues who are not lucky enough to be in the 10% group are going to be screwed, largely because of the actions of your attendings who opened the door to CRNAs in the first place.

So you see, it really wont matter that MDAs can still do the 10% "complex" cases, because that WONT HELP THE BULK OF THE MDAs who very rarely do those cases. A few superstar specialized MDAs will continue to make $$$, but the bulk of the profession is going to see a sharp salary drop.

Your argument is like me saying that a business entrepreneur (in general) makes more money than a radiologist. It arbitrarily assumes that the business owner will open up a hugely successful business, which is NOT AT ALL a given. 90% of all small business fail, so to claim that an entrepreneur makes more money than a radiologist is based on the inherent fautly assumption that you are assuming the business owner falls into the highly successful "10%" group. This "10%" group is NOT representative of all business owners at large.

Likewise, your faulty assumption is that MDAs will always make more than CRNAs, based on their ability to bill for the "10%" group of complex procedures. What you fail to understand is that there is NOT ENOUGH of the "10%" group of procedures to go around to 100% of the MDAs. Lots of MDAs are going to be squeezed.

so MacGyver, again, bite me...

I can tell you've taken a liking to me. Like I said, you are already a resident (i assume you are a not an attending) and the changes I'm talking about occur in the long term. So you've still probably got a good 20 years before the CRNAs catch up to you. Tell your attending colleagues who started this mess that I hope it was worth selling their profession down the river so they could make extra $$ by billing for supervising CRNA procedures.

 

[MacGyver]

Where do you get this fearmongering stuff?!?? Do you just make it up? You have such an alarmist imagination and penchant for creative license I'm starting to think you should give up medicine and be a paperback fiction writer.

You're right, I was wrong.

CRNAs actually provide 65% of all gas in the country, not 70%. I was off by a whole 5% 😴

Some of that is "supervised", of course, if you count "supervision" as the MDA being in a different OR suite at the time and never once entering the room to "supervise" the CRNA.

http://www.aana.com/crna/careerqna.asp

As anesthesia specialists, CRNAs administer approximately 65% of the 26 million anesthetics given to patients in the United States each year.

 

[jwk]

You're right, I was wrong.

CRNAs actually provide 65% of all gas in the country, not 70%. I was off by a whole 5% 😴

Some of that is "supervised", of course, if you count "supervision" as the MDA being in a different OR suite at the time and never once entering the room to "supervise" the CRNA.

http://www.aana.com/crna/careerqna.asp

65% of the anesthetics in this country are NOT provided by CRNA's working and billing independently of anesthesiologists in solo or CRNA-only practices, which is what the AANA would have you believe.

I don't have any exact percentages, but I think I recall something to the effect that 65% of the anesthetics administered in the US have involvement of an anesthesiologist, whether he/she personally administers the anesthetic or provides supervision or medical direction. I'm sure someone will correct my numbers if they're incorrect. Tenesma, help me out here. 🙂

 

[Tenesma]

macgyver - i am an attending...

 

[Old MD]

oh really... you can do 100% of what an MDA can do...
so that must mean you can:

1) become director of a PACU
2) provide ICU back-up coverage in community hospitals
3) do an 11 hour old 32 weeker premie for a bilateral craniotomy for Grady IV bleeds from forceps delivery (who by the way has a right to left shunt)
4) do a lung transplant
5) do a liver transplant and manage CVVH at the same time on a hepato-renal syndrome patient
6) do an elective thoraco-abdominal aneurysm repair w/ spinal cooling and lumbar drain
7) provide critical care management in the OR for intra-operative catastrophes ....

and the list goes on...

knowledge doesn't lead to different clinical outcomes???? are you kidding me?... MacGyver, while I agree with most of your postings about the increasing presence of midlevel providers, you can't be serious about the above quote... The whole point of gaining more knowledge is to create an environment for better clinical outcomes. Just look at a graduating CRNA who will have a total of 1600 Clinical Hours vs a graduating MDA who will have a total of 10,000 clinical hours (and that doesn't include the 4000 clinical hours during internship). Who do you think will have a higher success w/ their thoracic epidurals? Who do you think will have a deeper understanding of the variety of odd medical diseases...

And you keep on saying the market won't support higher salaries.... why are my colleagues getting 300-350k/year working in states that have opted-out of physician supervision for CRNAs... In fact, despite the increasing strength of the AANA we have yet to see a dip in the salaries of MDAs - if anything they continue to be as strong as ever... and as far as insurances paying MDAs and CRNAs the same... guess what??? they already do in many areas... i think medicare still only reimburses 85% for unsupervised CRNAs though (so still not perfectly equivalent).

anesthesia gets reimbursed based on units, the reason MDAs make more, is that the more complicated cases get more units...
1 unit =15 minutes (simplified explanation) ...a thoracic epidural is 7 units, an a-line is 1-2 units, etc... you can see how the bigger the case, the more complicated the monitoring , the more money can be charged based on units, plus time spent on the case.

as far as high-risk OB goes.... there is high-risk and there is HIGH_RISK... believe me, no HIGH_RISK OB is going to be at an all-CRNA hospital.

Funny... i coulda sworn there were a bunch of anesthesia nurses in here nattering about how CRNAs can do everything an MDA can. One of them GASCRNA even called out to Tenesma to support her beliefs. They seems to be awfully quiet after Tenesma replied.

Btw tenesma are you a he or a she?

 

[GASCRNA]

By the Way Old MD, Tenesma, Mr. Money ect... GasCRNA is not a female and I have news for you. I Have my own pain practice where I do nerve stim implants as well as fluoroscopy guided blocks. I have worked at small community hospitals where not only do I run a ICU but yes also put in all invasive lines and run a outpatient pain clinic. Yes I ahve done lung, liver transplants as well as open hearts under what you call "supervison" where I never once saw my "supervisor". So Iam not sure what your blabbering about when you say you can do things I cant do ? I must have missed the boat when I thought I read and studied Guyton, Cousins, ect..are these not the same books you studied in med School or anesthesia residency ? You must just be extra special because your a MD and Im a RN and have some extraordinary knowledge that I dont have after studying this for 8 years as well as practicing for over 10. Are MDs somehow given carte blanche that once your done being educated you know everything and dont need to study anymore?? Wow ! Iam not aware of any profession that possess some superior knowledge that implies that are better than everyone else. Are we suppose to think that MDs are the smartest people to walk the planet ? Get over yourself and accept that their are people that are educated that may not be MDs that can do your job. If you dont like it maybe you shouldnt have gone into anesthesia!! For gods sake give it a rest !! 😀

 

[Catfish John]

"You must just be extra special because your a MD and Im a RN"






You are damn right we are extra special.

Maybe you should have applied to med school and gone for the highest level of medical training the world had to offer if you want to be number 1. But you elected not to and decided to take short cuts...so you can go ahead try to convince yourself you are trained just as well, if it makes you feel better...

 

[painmanager]

Seriously, I'm sick of these people saying they're just as good as doctors. Yeah maybe you ran were allowed to do some procedures in some crappy backwater hospital, great. I guess that makes you fully boarded in critical care. Again, difference between being a technician(you), and having knowledge(us). You are, and never will be, as good as an MD, plain and simple. I won't argue that with you because you didn't go to med school, didn't do a residency, so you have no idea what it's like. Kid yourself if you want, but when it boild sown to it, you are just a murse who got a little bigger bite of the cheese, probably because the town you work in is a ****hole that no MD would even drive through it.

 

[Mr_Money]

By the Way Old MD, Tenesma, Mr. Money ect... GasCRNA is not a female and I have news for you. I Have my own pain practice where I do nerve stim implants as well as fluoroscopy guided blocks.

Scary....those poor patients! But in the boondocks of the Mississippi or the foothills of West Virginia I guess they don't know any better 🙄

I have worked at small community hospitals where not only do I run a ICU but yes also put in all invasive lines and run a outpatient pain clinic.

See above. Additionally, how do you "run an outpatient pain clinic" if you can't even write prescriptions, Einstein? What do you tell everyone? "Oh, just go home and take some Tylenol". Please.....

Yes I ahve done lung, liver transplants as well as open hearts under what you call "supervison" where I never once saw my "supervisor".

I'm gonna have to call "bullsh*t" on this one. Listen, you've got to stop listening to those voices in your head, nurse!

So Iam not sure what your blabbering about when you say you can do things I cant do ? I must have missed the boat when I thought I read and studied Guyton, Cousins, ect..are these not the same books you studied in med School or anesthesia residency ?

Just a clarification.......doctors CONVERSE, nurses BLABBER. These may be the same books we studied, but therein lies the difference. MDs have an in depth knowledge of what is contained in these texts, not just a superficial understanding like nurses do (if they even have that).

You must just be extra special because your a MD and Im a RN

The only sensible thing said thus far.

Are we suppose to think that MDs are the smartest people to walk the planet ?

Yes. Acceptance is the first step to recovery!

Get over yourself and accept that their are people that are educated that may not be MDs that can do your job.

You're right at last!! Those people are D.O. anesthesiologists!!!

Peace out! QOD

 

[trapper john]

I was at a conference a few months ago and was sitting at a table with a DO anesthesiologist and a CRNA. After some small talk, the DO asked the CRNA "what do you think of the whole AA issue?" No exaduration, the CRNA literally turned pale and said "let's not talk about that please". The DO continued:

"You know, it's all about greed. A few years after I was in practice, one of my partners started bragging that due to "shortage" of jobs for anesthesia docs, that we could get one for $60K. I told him that kind of stupid greed would be the death of us all. Now CRNA's are bragging about how they don't need medical supervision, how they can practice autonomously, and are expecting MDA salaries. So the next thing is the AA's. It's so silly because there is plently of work for all of us".

I'm a resident in the last year of my training. I've had some great help from our CRNA's throughout, and have learned a lot from them. They too have told me they have learned from me as well. One day I was with a guy who is univerally regarded in the department as the best CRNA. I was showing him a complex EKG from a patient I was pre-oping. He stopped me and said "I'm glad you know what that is, because I have no idea what you're talking about!"

I value the role CRNA's and AA's play, but it's like the line from Dirty Harry:"A man's got to know his limitations". The issue here isn't ego, it's QUALITY of patient care. A CRNA running an ICU? God, I've already done 3 months of CCM in addition to a year of internal medicine, and due to the fact that my PD likes to be way ahead of the curve, I'm stuck with another two months in my "elective year". It seems the ABA will soon be requiring 6 months. Still if I wanted to "run" an ICU, I'd do a CC fellowship.

GASCRNA: I find it interesting that any hospital would grant you privledges to put in nerve stimulators which is a surgical procedure. I am doing extra pain training this year, but wouldn't even think of doing invasive stuff like that on a regular basis without being fellowship trained. Just wait until you mess up, and have a fellowship trained pain doc testify against you.

Oh: And you think you know medicine as well as a physician? Great, let's see you pass the USMLE I,II,and III. Then even better, pass the Anesthesiology written and oral exams. Do that and and you can lay claim anything you want. Until that time, why don't you go find a CRNA forum to hang out on.

 

[Catfish John]

"accept that their are people that are educated"

 

[GASCRNA]

hmmmm better check your references Einstein..I work in a major metropolitan city and employ.. yes employ MDA's. Oh I forgot you are just as brilliant as Einstein...where is the moderator and how can the language and outrage and jealousy you show even be posted on here ? Moderator, what are you moderating?? Freedom of speech absolutely but until each and every one of you who know absolutely how some of us are educated you should keep your lip zipped and just face the fact their are other people out there that can do your job just as well or better than you.

 

[painmanager]

It's just that the stuff you say makes no sense at all. You are talking about doing things that require MDs to get fellowships to be able to do. I mean, I might as well just skip my anesthesia residency then and go shadow a pain management specialist for a few months, learn some techniques, and then start practicing right? Or I could just schedule a bunch of CC months right now during internship, and then go out and start being an intensivist. There are rules, boards, certifications, diplomas, for a reason, to make sure that you have proven to someone who knows more than you that you are capabale of doing the job. Sounds like you practice very dangerous medicine. I don't know who's stupider, you, the hospital that grants you prviledges, or your patients for not even taking a second to do their homework. But the others are right, your as# will get sued soon enough, and you can continue your idiotic posts from a jail cell as someones girlfriend.

 

[jwk]

hmmmm better check your references Einstein..I work in a major metropolitan city and employ.. yes employ MDA's. Oh I forgot you are just as brilliant as Einstein...where is the moderator and how can the language and outrage and jealousy you show even be posted on here ? Moderator, what are you moderating?? Freedom of speech absolutely but until each and every one of you who know absolutely how some of us are educated you should keep your lip zipped and just face the fact their are other people out there that can do your job just as well or better than you.

You're among the dangerous breed of CRNA who thinks they are the equal of anesthesiologists in all things. It simply isn't true.

Nerve stim implants? That's not anesthesia - that's surgery. That simply is not in the scope of practice of a CRNA. Is your state nursing board aware that you're doing this?

Where would you even get the training? That's certainly not in the standard nurse anesthesia curriculum. I'm surprised the stim manufacturer would even be allowing you to use their implants. And I'm totally shocked that any hospital would allow you privileges to perform them. Maybe a little outpatient surgery center is that greedy, but a hospital in a "major metropolitan city"? Give me a break.

Oh - and about the little freedom of speech comment and the whining to the moderator? Let me paraphrase what I get told so often on one of the CRNA boards - don't come to a MEDICAL discussion board and whine and complain because the majority of people posting don't agree with you. If you want everyone to agree with you and praise you for operating outside the envelope of standard nurse anesthesia practice, go back to the CRNA bulletin board.

 

[GASCRNA]

Its *****s like you that give all MD's a bad name ! I suggest you actually do your home work and look at scope of practice for CRNA's and look at state regulatory guidelines for advanced practice nurses and CRNA's. Oh by the way we can write prescriptions as well..duh enough said !