CRNA=MDA??

[diesel]

I'm applying for anesthesiology, but after seeing a CRNA do an OB case, or any other case for that matter, without any supervision--there are no MDAs at the hospital. I've become quite uncertain of my choice. First of all what's the point of OB fellowship training when joe CRNA can do it? Nobody really knows if your're an MDA or CRNA and nobody cares. I dont want to be thought of as a CRNA after 8yrs training, does anyone feel the same?

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[MacGyver]

The perpetual mantra of anesthesiology is that CRNAs dont do the really interesting/complex cases.

The reason this mantra is flawed is due to the mistaken notion that this will not change in the future.

CRNAs are doing surgeries now that they never would have attempted 5 years ago.

5 years from now, CRNAs will be doing the stuff thats supposedly "off limits"

Once you give up turf to non-doctors, they will take every inch of it and then some.

The problem is that MDAs got greedy--they wanted CRNAs to get these practice rights so they could use them in their group practice and make more money.

The MDAs of today are selling out anesthesiology for $$$$

 

[gaseous]

Do we really have to get into this discussion again. Do a search if you want to know what everyone thinks.

Put the issue to bed...

 

[diesel]

Gaseous,

I realize that, but nobody has answered the question of what is the purpose of OB fellowship training, when a CRNA can do it? I dont think CRNA's have fellowship training.

 

[Gator05]

I'm guessing you were at a community hospital. You'll also see non-fellowship trained practitioners perform hearts, neuro cases, and peds cases.

These aren't the same subspecialty cases as those you'd see at a tertiary care facility. Putting tubes in the ears of a 5 year old is different from the repair of a CDH anesthesiology-wise, for instance.

The answer to your question is the fellowship readies you for higher-risk OB, and the ability to teach it to others with a bit more confidence.

Agree with the above post; this is an argument that has been rehashed over and over.

 

[gaseous]

I guess your right. I don't think an OB fellowship is worth very much. Do you really need a year to learn how to do spinals and epidurals. Even without a fellowship you are qualified to work in OB, SO whats the difference?? An extra year and lost pay. I know in some places the CRNA's are putting in epidurals and spinals. It all depends on location and how much the anesthesiologist feels comfortable with the CRNA and his or her skills. I don't think there are any "laws" in place to prevent it.

An anesthesiologist I know in private practice uses his CRNA's to get to room ready for epidurals so he can roll out of bed, insert the needle and go back to bed when on call. Not too shabby.

 

[diesel]

Yes it was at a community hospital, but the patient was definitely a high risk case. Black female needing a c-section due to diabetes, HTN, macrosomia, etc. So the consensus seems to be that if your're at a community hospital a CRNA=MDA, but at a tertiary center an MDA needs to have fellowship training?

 

[Gator05]

Fair points. I still don't think this is all that much of a high-risk case anesthesiology-wise, but it is high-risk obstetrics. I've always thought of fellowship training as what you wanted if you desired to teach anesthesiology in an academic/tertiary care facility.

 

[diesel]

I think any case for OB would be higher risk for anesthesiology wise due to physiologic changes of pregnancy, especially with hypertension and diabetes. It's just disheartening to see a nurse perform the core cases that I will be doing for the rest of my life after years of training.

 

[Tenesma]

diesel

what gator5 said is accurate - for OBs HTN,DM represents high-risk as the risk for fetal demise or morbidity is high.... however for us (anesthesia), very few of what OBs consider to be high risk is actually high risk for us.... while it is true that pregnancy does present some physiologic changes as well as anatomical changes, there are far more complex cases in OB.... for example, i did a lady who had neurocystocercosis w/ worsening hydrocephalus who also had congestive heart failure (due to her first pregnancy) - now that case is far more complex, etc.... one thing is for sure, that case would never be done in a community hospital, and would most likely get the attention of an MD.

CRNAs will be around for a long time to come and they provide the excellent service of providing great anesthesia, but don't let that discourage you... once you go through your anesthesia training you will quickly see the differences that exist.

Now as far as OB fellowship training - it is only useful if you are planning to do academic OB anesthesia, or if you are seeking a high level job at a major OB center.... I know some practices in 100% OB anesthesia are actually looking for OB trained anesthesiologists (and the money is nice too, you are talking 400k starting, but you work your ass off).

However, i personally, find most of the bread and butter cases boring, and i have no problem with a CRNA providing the care... with the level of sophistication of our drugs and monitoring equipment anesthesia has become very safe for most straightforward patients.... what i look forward to are the cases that make me think, that make me think outside of the box, the unusual cases... it is a great field - don't be discouraged...

 

[trapper john]

God, I'm on my zillioneth OB call in the past three months as our juniors aren't even allowed to start doing OB until October.

One of my OB/Gyn resident friends on hearing that one of the staff anesthesiologists was fellowship trained said "you'd have to be crazy to do an OB fellowship". Nuff said! Man, I might just wind up doing hearts, just so I never have to take an OB call as an attending.

The CRNA thing is way overblown. There's actually a big shortage of them too as the older ones are retiring, and the schools are not keeping up. Plus with the whole AA thing on the horizon, they're getting worried.

Gas is so good right now it's unreal, and the outlook lines great for at least ten more years.

 

[gaslady]

There's also a shortage in the potential applicant pool for CRNA school. Critical care nursing experience is required and there's a national nursing shortage.

 

[womansurg]

Originally posted by The_Gas_Man
The nurses CANNOT do it..........what you are observing is simple cases that are within their realm

Simply not true.

At the VA associated with my residency, the CRNA's put in the epidural, intubated, floated the swan, titrated the pressors, monitored the fluid status, and otherwise ran the case on our abdominal aortic aneurysms. In five years there I met the overseeing anesthesiologist one time, when he came over to sign some paper work at the end of the day.

We also did pneumonectomies with dual lung intubation, carotids, and every major abdominal case you can think of. We did a pheochromocytoma once; our CRNA ran the nitroprusside and neo drips without a blinking an eye.

There is hardly a VA patient alive who is better than a class III anesthetic risk. Heart failure was the norm. Diabetes, renal failure, recent MI...you name it. Many were class IV and we certainly did our share of V's as well. This is a very elderly, very neglected, very ill patient population.

They did good work and they earned my respect over the course of time and experience. I'm sorry if that offends you, but that doesn't make it less than true.

 

[UTSouthwestern]

At our VA, the CRNA's do a lot of difficult cases as well. You can teach monkeys to do any technique. PA's could do a number of surgical procedures if allowed to. The difference lies in levels of management and understanding not just the first or second or third options available, but ALL levels of physiology, pathology, pharmacology, and treatment.

The better CRNA's who have been in the field long enough and have had the opportunity to work the difficult cases can certainly run them. There is no secret to placing lines, intubating, or running drips, just as there is no secret to cutting bellies, chests, extremities, or heads. The difference consistently lies with the ability to manage critical (and even simple) complications quickly and correctly.

Not all hypotension requires fluid boluses or pressors.

Not all hypertension requires beta blockers, alpha blockers, nitrates, or more volatile.

CRNA's are well trained clinically by physicians to know as much as they do about the equipment, drugs, and surgical situations.

They are excellent colleagues that are an invaluable component of any anesthesia team.

They are not physicians. They do not have 4 years of anatomy, biochemistry, pharmacology, physiology, clinical internal medicine, surgery, family practice, pediatrics, OB/GYN, and psychiatry. Their training omits clinical training in the diagnosis and treatment of systemic illnesses that are all to often a part of your difficult surgical patient.

If you are fortunate enough to have a surgical practice with ASA I and II patients only for the rest of your life, you can probably do without an MDA. That one patient with hidden/undetected pathology or the complex, multisystem pathology teetering on the edge of life and death is the only one that is necessary to destroy your career in the private world.

Are MDA's perfect? Hell no. Much like our surgical colleagues, there is an unfortunately diverse level of skill among the members of our profession.

The question you should ask yourself is would you rather trust the care of your family member to an experienced surgeon well trained in their field of specialty AND in the other disciplines of surgery who has been trained by similarly trained MD's or would you trust one fresh out of a small/private/cush residency with adequate training in their field of specialty and little else?

Likewise, among MDA's and CRNA's would you rather have a physician with 8 years of medical school, clinical, and academic training or a CRNA? The answer can be argued by both sides (and has been for many, many years), but for my money, I want the physician who can see each situation with a physician's perspective and be able to know when it is and is NOT appropriate to use the multitude of equipment and drugs we have available for every situation.

I want the anesthesiologist who has run the codes, made the life saving decision, recognized the bizarre arrythmia before it was too late, understands the acid base disorders, sees the electrolytes as more than numbers to treat, and understands the complex interactions of cardiovascular, pulmonary, renal, hepatic, neurologic, and psychiatric pathologies.

I want the person who can not only put me to sleep and wake me up, but the one who gives me the best chance of waking up with my body in the same or BETTER condition than it was when I went to sleep. I want the person has vision to not only monitor the vital signs and gas monitors, but the one who sees the most obvious to the most minute details of every case without having to think twice about it.

As I would select any Southwestern trained surgeon to treat a member of my family over a surgeon from almost any other program, I would likewise select MOST MDA's over the independent/unsupervised CRNA.

Anesthesiologists have no one else to blame but themselves when they look at their field and see other physicians and nurses encroaching on once proprietary fields. We have willingly trained our competition in general anesthesia, pain management, and critical care. That being said, the experts have been and will continue to be the physicians that continue to work at expanding the field and willingly provide their knowledge to train anyone who desires to learn them. To deny that is to invite an element of chance that will make you ponder this question again in your future.

 

[Gator05]

Again, I'm disturbed by the comparison. A PA can do cardiac caths, can probably be taught to put stents in, can figure out when to run tPA, can take care of patients in the cardiac ICU, etc etc. Does this make them a cardiologist? No. Does this make them extremely competent in taking care of very sick patients? Yes. One major difference lies in their responsibility; it ultimately falls on the cardiologist.

Womansurg, in these Class IV patients with a severe cardiac history, are they performing intraoperative TEE? Who runs the critical care units? The PACU? I mean no offense, but I'd be disappointed if there weren't extensive participation by MDA's in these places.

I, too, have met some extremely well trained CRNA's. They were also honest enough to admit deferring some of the more complicated cases; sure, they could DO them, but they weren't the best person for the job.

 

[MacGyver]

All of you guys are splitting hairs here. You are trying to make fine distinctions that are artifical for the most part and very fluid and subject to change. Do you really think that in 10 years CRNAs wont be more advanced than they are now?

I GUARANTEE YOU that in 10 years CRNAs will be doing things that are unheard of now. They are rapidly closing the gap between themselves and MDAs.

As new surgeries are developed, the MDAs will initially control it, but since they tend to be greedy and want to make as much money as possible, they always start training CRNAs how to do them to the point where they can practice independently.

Anes salaries will be stagnant long term. How can you justify paying someone double what a CRNA makes if the CRNA can do 90% of what the MDA does?

Sure, a CRNA will never hold the anes PD position at a major academic hospital, but by and large they will be doing the same tasks as full blown MDAs.

MDAs better protect their turf better or longterm the CRNAs are going to strip away all the bread and butter surgeries and MDAs will only be called in to the very risky stuff like conjoined twins. Thats not a good job market for MDAs folks--MDAs need to hold on to the bread/butter surgeries.

 

[Justin4563]

macguver is the most intuitive and the most observant ones in this bunch.........

The reason why anesthesiology is dead!!!!! and it will prob in 100 years wont exist anymore are the anesthesiologists who sell out the specialty for money... Its all about the cash....

Instead of doing a case on your own they need crnas or residents with them. maybe 3-4 of them running 3-4 rooms making more money.. But the crnas got smart and said " we want part of the action" and they got it.. The anesthesiologist gets a lot less pay for medically directing a crna then they used to.. Then the crnas said, you know what we dont even need the MDA or DOA for supervision and went to congress and told them that and congress said youre right. and it almost went through.. Nationally.. now the states are opting out of the supervision rule one by one.. ha ha ha ha.. and Im an anesthesiologist who works alone and I hope the crnas take over.. would serve the greedy anesthesiology community right.... Just look at how the American society of anesthesiologist rapes the profession and how the american board of anesthesiologists makes exams and administer exams.. that costs almost three thousand dollars.. I have absolutely no RESPECT for the leadership in anesthesiology.. They are all "in it for myself" "what can i do for me" how much money can we make from these sons of bitches kind of people" I would urge someone who is thinking about a career in anesthesiology to look elsewhere.. but where? maybe law or accounting or something like that..


and yes crnas can do it without anesthesiologists, but there would have to be a lot more input from the surgeons and the surgeon would have a lot more liability.. The anesthesiologist sole existence is for someone to blame when **** goes wrong..
Im sorry but Ive been at this a while.. i see the handwriting on the wall...... LOL... its all good... I learn from my mistakes...

 

[UTSouthwestern]

In a way, I guess I should cheer on Justin so that fewer people will choose anesthesiology. Regardless, if you're confused and you're reading this, pick the profession you feel you will enjoy the most. Justin obviously loves his legal profession more than his medical profession.

 

[Tenesma]

it is interesting how this question comes up on a regular basis, either because of 1) applicants who have heard a lot of discussion regarding CRNA vs MD 2) non-anesthesia people stirring up the pot....

2 big points:

1) skill sets: while you can train any monkey to do a procedure - there is a HUGE difference in skills between graduating CRNAs and MDs..... the required CVP lines are 5 for CRNA graduation (go to AANA.com and look up certification guidelines) - and if they are performed on manequins that counts too.... your average anesthesia MD at end of residency (and this number DOESN'T include the lines placed during a medical or surgical internship) has placed 200-300 central lines.... CRNAs have to have placed 25 a-lines, anesthesia resident has placed 400-500.... the list goes on....

2) clinical exposure: the required clinical hours for CRNA graduation is on average 1600 hours.... Clinical hours for your average MD at end of residency is between 9,500 and 11,000 hours.... and that DOESN'T include the 4000 hours of patient management from internship....

and relying on a surgeon's opinion on what makes good anesthesia is a waste of time, as their's is entirely bogus and biased.... their criteria for judgement are based on their exposure.... just as anesthesiologists we prefer surgeons who are fast and don't lose any blood, but I know for sure that surgeons would argue that there is a lot more to being a competent surgeon than that

so for those who are worried about CRNAs... don't be... they have their role, MDs have theirs.... and for future anesthesia residents: it is a great field (one that i enjoy every day)

 

[jjjez]

Of course, let's not forget that Registered Nurses are accountable for their own actions. Remember that if an MD prescribes the wrong drug or wrong dosage and a Nurse gives it, it is their fault not yours. Ergo if a CRNA screws up in anesthesia, it is their fault, not the MDA (if their is one) and certainly not the surgeons.
Furthermore, considering that Nurses were gving anesthesia before MDA's wouldn't that logically mean that you are encroaching on their territory and not the other way round.
Also it probably isn't logical to say that CRNA's turf all the diificult cases to the MDA's when CRNA's outnumber you, it doesn't sound quite right to claim that the 'harder' cases are waiting for an MDA to do them. As for clinical hours, aren't the CRNA's qualified anyway, surely after 3-4 years of training and 1- 5 years experience before entering CRNA school, they must have racked up a few hours. Anywho. i'm not an MDA or a CRNA, just a student nurse in the UK. Ironically we don't have CRNA's, therefore we have countless delays in actually getting patients into theatres because of a chronic lack of anaesthetists. (British spelling and term). although apparently were going to have them soon. Here's hoping huh.
Sounds cool though, the cash that MDA's make. It's seen as a bit of an anti- climax to ones medical training in the UK. Weird huh?

 

[Tenesma]

a few points in response:

1) RNs are responsible for their actions when they screw up - but trust me, in a lawsuit everybody gets named (especially the doctors and the hospital) because of the amount of money involved - just look at RNs insurance premiums vs MDs premiums...

2) your logic that since Nurses provided anesthesia before there were Anesthesiologists - and thus anesthesiologists are encroaching on their field, is erroneous.... Dentists were the first to use anesthesia, followed by medical students - way before nurses were allowed to stand at the bedside and drip ether. So based on your logic CRNAs are encroaching on dentists and medical students???

3) Your next point is flawed as well... a higher proportion of ASA III and IV get done by anesthesiologists than CRNAs for two reasons 1) CRNAs are primarily distributed in rural/suburban environments where as MDAs are primarily in urban/academic environments - and most tertiary referral centers (where "harder" cases get done) are urban/academic. 2) level of training

4) your statement that CRNAs must have racked up enough experience before CRNA school was probably a typographical error - because CRNAs have absolutely NO anesthesia experience before CRNA school.... sure, after CRNA school and a few years of experience will make most CRNAs relatively competent at providing safe anesthesia for most patients. But i'll go back to my original point of CRNA=1600 clinical hours of anesthesia/patient care vs MD=10,000 hours of anesthesia care (plus another 4,000 hours of further patient care as interns, plus another (in my case) 3,200 of ICU patient management)... there is a discrpeancy in breadth and depth of training.

5) the reason there is a delay of patients getting into theaters (or ORs) has very little to do with the anesthesia provider deficiency, but rather with the miserably failing system of socialized medicine that exists in the UK.... the same system (or similar at least) is set up in CANADA, where for the most part there are more than enough Anesthesia providers, and they still have 6 month delays for elective surgeries...

6) as far as the cash that anesthesiologists make - it is well earned - and obviously insurance companies feel it is money well spent or else they would have contracts with CRNAs alone and would refuse to pay us way above CRNA salaries for the services we provide

 

[KMcHugh]

Posted at another site, but will repost here:

There are some things Tenesma says in that post that are quite true, while others appear true on the surface, but need a little deeper examination. Let's look at each point he made:

1. True, with a proviso. Generally, lawyers and plaintiffs see the hospital and the physician as having the "deep pockets." You don't sue poor people, there's no money in it. However, I've never seen any data to suggest that awards for malpractice are higher in cases involving MDA's over cases involving CRNA's. CRNA's insurance premiums are lower, however. Much of that is due to MDA's doing things that are outside the scope of practice of CRNA's (prescriptions, pain management surgical procedures, etc), and therefore there are more things an MDA can be sued for.

2. True on it's face. However, nurses were the first to perform anesthesia as a specialty. Prior to nurse anesthetists, anesthesia was not performed by fully certified physicians, because the surgeon is the head cheese in the OR, and no doctor wanted to play second fiddle to another doctor. So, initially, medical students were tried out as anesthesia providers, but morbidity and mortality rates were too high. Nurses were then trained specifically to administer anesthesia. M&M rates dropped significantly. In my mind, this was the first proof that anesthesia needed to be a separate discipline. However, none of this is proof that one group is infringing on the turf of the other.

3. Well.... I work in a very rural hospital, and we have no MDA's. (This is an update, I have moved here since last posting.) We do what are considered to be big general surgery cases (including whipples), and I do anesthesia for ASA III and IV patients routinely. As to the tertiary centers, what Tenesma said would be true if the cases were being done by MDA's. In many, if not nearly all of those tertiary centers, the anesthetic for nearly all cases, from endoscopy to open heart procedures is actually done by a CRNA under MDA supervision. Often, that supervision means the MDA is in the room only for induction. Where I was before, I did a large number of cases, including open heart and intercranial procedures essentially by myself. The supervising MDA sat in the corner while I induced the patient, while I inserted the necessary lines, then left to mess online with his stocks, while I did the anesthetic. Unless I paged the MD so I could go to the bathroom, the next time I saw the MDA was often in the physicians lounge after I had dropped the patient off in the PACU or ICU.

4. True enough. But then, before beginning their residency in anesthesia, new graduate doctors don't have experience with anesthesia, either. As to the hours of education, I'm presuming Tenesma is including hours in medical school. Most medical schools offer no classes in any specialty, but rather teach a general medicine curriculum. Prior to beginning an anesthesia residency, most medical students contact with patients has been very limited and highly supervised. Nurse anesthetists, on the other hand, have had at least a year of experience working directly with critically ill and injured patients. And its difficult to compare the education received by MDA's to that received by CRNA's. The education received by CRNA's is highly focused on providing anesthesia, which MDA's get none of until they actually begin a residency.

5. Exactly correct.

6. This would be true if and only if MDA's could bill at a higher rate than CRNA's. In other words, if a CRNA could bill $X for anesthesia provided for procedure A, while an MDA could bill $X + $Y for the same procedure, then Tenesma could make this statement. However, the truth is that for any procedure, the amount that Medicare or insurance companies will pay for the anesthetic for that procedure is always the same, regardless of whether the anesthetic is performed by an MDA, a CRNA, or a CRNA under MDA supervision. In other words, insurance companies and Medicare don't care who does the anesthetic.

The fact that MDA's make more than CRNA's has nothing to do with insurance companies, it has to do with what MDA run groups are willing to pay CRNA's. That's why most anesthesia groups want to hire a larger percentage of CRNA's. The last figures I read said that an anesthesia provider, working full time, could expect to bill about $200,000 - $250,000 for their services. If you ran an anesthsia group, and had to pay $150,000 to employ a CRNA, versus $225,000 for an MDA, which provider would you hire?

However, there is an interesting counterargument spawned by Tenesma's last statement. Since insurance companies pay the same for an anesthetic, regardless of who does it, perhaps they are aware that an anesthetic performed by an MDA is no safer than one performed by a CRNA. Otherwise, they would reimburse at a higher rate for MDA's, and would demand that MDA's perform the anesthetic for certain procedures.

Kevin McHugh, CRNA

 

[jester]

I have been very impressed by the dialogue on this very controversial topic. Just a few comments.

1) You work in a rural area with no MDAs. I think this will be the only situtation where CRNAs are allowed to practice by themselves. It is unlikely that at any major insitution will a CRNA be allowed to "practice" by themselves.

2) As for salary. Many CRNAs make well over 100k, while only working 40hrs/week. You ask why would you want to pay MDAs a lot more. Well, many MDs don't work shifts and do work weekends and take call.

3) In the 1990s many people didn't go into anesthesia b/c they were afraid of being replaced by CRNAs. Clinton was a big proponent of this to cut costs (and I think his mom was a CRNA). Now, I ask you this. If President Clinton needed surgery, who would do the case? CRNA? unlikely.

4) MDAs supervise CRNAs and residents b/c they have been trained to handle everything. Many board certified anesthesiologist have a wide breath of knowledge and a profound understanding of the magnitude of placing someone under anesthesia.
5) I think CRNAs have a place in practicing anesthesia, but I don't think they could replace MDAs. If this was ever the case, we better rethink medical education.

 

[Tenesma]

kevin:

here are a few replies

1) regarding mortality and morbidity dropping once nurses took over anesthesia.... there are NO studies to show that this is true, the only studies regarding mortality and morbidity occured after the introduction of the cycling blood pressure cuff (dynamap) and after the introduction of the pulseoximeter... where the mortality rate went from 1/15,000 to 1/250,000.... those were introduced by physicians...

2) regarding whipples being a big surgical case - i agree from a surgeon's point of view.... but from an anesthesia point of view it is actually quite boring. what makes a case difficult is the patients underlying complexity prior to the surgery even starting... like for example, would a rural hospital do a big general surgery case on a patient with severe aortic stenosis AND severe aortic regurgitation and inoperable medically managed recurring unstable angina? don't think so... no surgeon would that case in a rural setting because they would be losing money on having to provide 30 days of free post-operative care in the ICU...

3) the hours i posted for anesthesia residents does NOT include medical school.... i work about 75 hours a week and work 45 weeks a year in the OR (i subtracted 3 weeks vacation, and 4 weeks of ICU), multiply that times 3 years and you have 10,000 hours of OR time by the time an anesthesia resident graduates (compared to 1600 hours of clinical nurse anesthesia exposure)... I will have placed 350 central lines, 500 arterial lines, floated over 100 swan-ganz catheters, etc.... (and that doesn't include procedures performed during my internship year)... Nor are we even mentioning my 8 months of ICU training by the time i finish residency (combination of internship and resident level ICU)... so while i agree that MDAs prior to residency have no clue about anesthesia, they definitely have a clue after residency just from a technical exposure point of view there is no comparison what so ever....

4) reimbursement - while you are correct about insurance companies paying the same amount whether anesthesia was provided by MD or CRNA - what you are leaving out is that a CRNA can only work in ONE OR at a time, while an MD can supervise FOUR ORs at a time.... and recoup 50% from each room

 

[ravanbj]

Nevertheless,
MDA=Doctor, CRNA=Nurse

--> CRNA's will always only be nurses!!! I wanted to be a doctor, not a nurse.

CRNA's are just nurses who wish that they were MD's. If they continue to push and cause trouble, MDA's will eventually consolidate their power and send them packing to unemployment as they will be replaced easily by AA's.

 

[Tenesma]

hey ravan...

two points
1) CRNAs are advanced practice nurses and therefore are not JUST nurses - they are useful adjuncts in the anesthesia team model... you will be going into anesthesia, you will see...
2) in reference to a previous post of yours, MGH is not malignant... even though we don't mind if the rest of the world feels that way about us - we like to have the reputation of tough cowboys!!! in fact all of my colleagues (residents) couldn't be happier...

 

[ravanbj]

I have no problem with CRNAs and will gladly work with them in th efuture. Bu t the fact is, I will be a doctor and I should be allowed to be proud of that. We all work had, very hard, to become doctors and we should be proud of out accomplishment. CRNAs are very good at what they do, I do not doubt that, and they are a great asset to the team. But as MDs we must accept that we are the captains of the team and everyone on the team has their role. Not everyone can give orders, just look at the military. There is a hierarchy and MDs are at the top. Yes, we must work well with others and be team players. We should not be arrogant and must be humble. But we are the captains and we should be proud and accept this role. CRNA's are not doctors!! That is the bottom line. CRNAs are always trying to prove that they are equal and/or better than MDAs. All I am saying is that let's be team players for the best patient care possible and let's understand that MDs are the leaders of the team, not the followers. Take pride in being a doctor, we deserve it!!!!!

 

[diesel]

Ravan,

That's a good thought and was the whole point of me starting this thread. But in the end nobody (patients, nurses, doctors, medical students, chicks) are going to realize you're an MDA unless your wearing an ID badge with MD after your name. It is a chilling truth and nobody can argue with that. Personally, I hate wearing dog tags.

 

[doc_strange2001]

Lets just accept it C+R+N+A will never equal MD or DO. As the field of surgery has advanced so has Anesthesiology. No one ever argues that a Nurse Midwife is equal to an Ob doc. There is a gap in training and skill level. And medical care is better having Anesthesiology as a speciality just as it is better for having OB/Gyn as a speciality. Yeah Yeah nurses and medical students were the first ones administering anesthesia but the entire field of medicine has since evolved since then. Bottom line is Anesthesiology a medical speciality and its here to stay. It has its place for CRNAs just as Nurse Midwives have a place in OB. If you want the skills, respect and responsibility of a doctor then you must go though medical school and residency and bust your a$$ like the rest of us.

 

[ravanbj]

WORD!! I agree completely! MDAs are doctors and CRNAs will NEVER be equal to us. If they want to, then they are free to apply to medical school and complete a residency training. MDAs will always control the field of anesthesiology! and we deserve the big bucks because we busted our A$$ for 8 years to get there.

Sounds like this debate has finally come to an end.

 

[diesel]

Isn't anybody listening? To the lay public (patients, most doctors, nurses, chicks) can tell the difference between an MDA or CRNA, because they do the same thing. Ofcourse, everyone here knows you cant compare the two and nurses will never be as knowlegeable. It's just frustrating to see a nurse take a couple of night classes, and become someone who does an MDAs job. So I say it again, and I don't think anyone can refute this simple truth about the field of anesthesiology, the only way people are going to know your a doctor is by wearing a name tag.

 

[ravanbj]

who cares man!?!?!?!? As an MDA, people will know you are an MDA when you tell them, surgeons you work with will DEFINITELY know who is an MDA vs CRNA. Believe me they will respect MDAs as colleagues and treat CRNA like nurses. My father defines the word COLLEAGUES as people who work together at a same educational level. As MDAs MDs are our colleagues, not CRNAs who are colleagues with other NURSES. Never sell yourself short, if you are an MD, your colleagues are MDs, not nurses. Put it this way, CRNAs are not allowed in the "Physician's Lounge" and at my institution they do not dare come in. So there is one advantage. Plus, who cares who knows who you are, people will know when you pull in >$400k and have a phat car and beautiful house. Just chill with caring about what people think, and be a great doctor, take care of your patients, respect people you work with, and all of the rest will fall into place naturally.

 

[Adcadet]

one question from a newbie for both the CRNA's (Kevin, especially) and MDA's (Tenesma, especially): what happens if a patient is in danger. How do CRNA's and MDA's work together then.

The reason I ask:
Way back when I was shadowing a colorectal surgeon who had to do a bowel resection on an older gentleman with multi-organ failure. The patient, who happened to be a respected physician himself, literally asked me if I had ever seen a man die as he was about to be induced. The fellow assisting the doctor was pretty pessimistic the patients odds of surviving the surgery. I seem to have vague memories of two people people standing around the monitoring equipment around that patients head, but I don't know who they were (I was preoccupied with other things). I suspect they were a CRNA/MDA team, and I'm curious about how CRNA/MDA teams work together on the really dicey cases.

 

[CougRN]

I personally don't want to argure CRNA vs MDA with anyone but I take a little offense to the post that we just take a few night courses to perform anesthesia. CRNA's do have their place in the OR and are not doctors. But our training is a lot more significant than just a few classes at night.

FIRST YEAR Hours Credits

Term 1-Fall (September-December)

ANE-504 Pharmacology I 45 3
ANE-507 Chemistry/Physics 45 3
ANE-505 Anatomy for Nurse Anesthetists 30 2
ANE-601 Professional Aspects I 30 2
ANE-603 Physiology I 75 5
ANE-608 Integrating Seminar I 15 1
ANE-621 The Legal, Economic, and Ethical Context of Healthcare 30 2
Subtotal 270 18

Term 2 - Spring (January-April)
ANE-604 Physiology II 75 5
ANE-609 Research Methods Seminar 45 3
ANE-606 Pharmacology II 60 4
ANE-602 Anesthesia Principles I 45 3
ANE-622 Principles of Didactic Instruction 15 1
Subtotal 240 16

SECOND YEAR

Term 1 - Summer (May-August)
ANE-623 Anesthesia Principles II 45 3
Subtotal 45 3

Term II - Fall (September - December)
ANE- 624 Anesthesia Principles III 45 3
Subtotal 45 3

Term 3 - Spring (January - April)
ANE-625 Anesthesia Principles IV 60 4
Subtotal 60 4

THIRD YEAR

Term 1 - Summer (May-August)
ANE-626 Professional Aspects II 30 2
ANE-613 Research Practicum 45 3
Subtotal 75 5

ANE-620 Clinical Review 15 1
Subtotal 15 1

Program Total 750 50

Clinical Training

Upon completion of the didactic portion of the program in April, the students move on to the 19-month hospital-based clinical portion of the curriculum. The primary focus is clinical anesthesia training. The clinical experience obtained will be of the width and breadth necessary for the student to achieve clinical competency in anesthesia. This is accomplished through affiliations at clinical sites throughout the New England area.

Each student will participate in at least 600 anesthesia cases. All of the surgical specialties are available, including hands-on training in regional anesthesia techniques. Specialty experiences (i.e. neuro-surgery, open-heart surgery, high-risk obstetrics) when not available at primary hospital affiliation sites will be obtained from short-term rotations at other medical facilities in the region.

All types of anesthesia techniques and the latest agents are available for student participation. Students are able to obtain experience in general anesthetics, intravenous agents, and regional anesthesia to include: spinal, epidural, axillary block, and Bier blocks

 

[Gator05]

Wow.

"Each student will participate in at least 600 anesthesia cases."
If a resident in anesthesia were only doing one case/day (in reality, the cases performed more likely average 2-3), then over 3 years they would perform over 1,000 cases by graduation. Rough estimates are that anesthesia residents participate in between 2500-3000 cases in their training, not counting ICU time.


"Students are able to obtain experience in general anesthetics, intravenous agents, and regional anesthesia to include: spinal, epidural, axillary block, and Bier blocks"

Obtain experience? Anesthesiology residents not only obtain proficiency and competency, but can pursue fellowships in regional and OB.


I'm glad that CRNA's do receive such excellent training; the intraoperative management of patients is a great responsibility that should demand the utmost of its practitioners. The ability to lead an anesthesia team comes from taking those extra steps beyond "obtaining experience" to become proficient and competent against even the most challenging cases.

When things go wrong, the patients family should not have to wonder if the person conducting the anesthetic is the best that medicine has to offer.

 

[trg2002]

"Each student will participate in at least 600 anesthesia cases."

Thus far, after a little more than 3.5 months of my residency, I've done just shy of 200 cases (and I can count the number of MAC cases I've done on one hand).

This has been an enlightening thread. I didn't realize that the difference in experience and training is so great.

 

[CougRN]

"Thus far, after a little more than 3.5 months of my residency, I've done just shy of 200 cases (and I can count the number of MAC cases I've done on one hand)."

Ok, so 200 cases in about 4 months. That would be 600 cases in a year. 600 cases for CRNA's in 19 months is an absolute minimum and not a number that anyone ever graduates with. On average in 19-months each student will do 1000-1100 cases. So that would equal out to be about the same for MDA students in 19 months and CRNA students in 19 months. But MDA students training is longer and they do gain more experience in that time. I just wanted to point out that in a similiar time period we do perform the same number of cases.

I understand that your training is very significant and challenging. I respect what you do and the training you get. But please don't think ours is a cake walk because yours is longer. We can work together.

 

[Tenesma]

there are still a few differences in those cases....
do you get exposed to doing some of the following?? 1) bilateral craniotomy on a 10 hour old 2) a cardiac cath on two siamese twins (age 2 months) connected at the chest and sharing a left ventricle 3) a liver transplant while the patient is on CVVH and you are directing the management of the CVVH 4) metopic craniosynostosis repair on a Goldenhaar baby with hypoplastic lower jaw 5) double lung transplant 6) carinal resection 7) tracheal resection and reconstruction 8) a ruptured thoraco-abdominal aneurysm with spinal cooling and draining.... the list goes on... and on...

CRNA training is adequate to provide safe anesthesia in most settings...

 

[ravanbj]

As long as CRNAa realize that they are NURSES not MDs, that's cool with me. I don't mind using them as little worker ants to do all the boring stuff like charting, appy cases, setting up the room, etc.. Whatever makes my life easier. I guess that's the reward for all the years of HARD work --> Having Nurses to help out with the easy mundane stuff. As long as we get the difficult challenging cases. And as long as CRNAs allow me to run multiple rooms and pad my wallet I am cool with it. Yes they make about 100k, but that is the limit. They reach a glass ceiling in their earning potential, while MDs the sky is the limit. I know people pulling >800k a year, and that is with th ehelp of CRNAs working like busy bees to help out. So relax, it's kind of nice to have CRNAs around (just like pilots have air crew to help out, they are a team but the pilots are still the captains). Just remember ALL MDs, make sure you keep the checks and balances system alive, ie do not let CRNAs take any more power than we want them to have.

 

[CougRN]

Originally posted by Tenesma
there are still a few differences in those cases....
do you get exposed to doing some of the following?? 1) bilateral craniotomy on a 10 hour old 2) a cardiac cath on two siamese twins (age 2 months) connected at the chest and sharing a left ventricle 3) a liver transplant while the patient is on CVVH and you are directing the management of the CVVH 4) metopic craniosynostosis repair on a Goldenhaar baby with hypoplastic lower jaw 5) double lung transplant 6) carinal resection 7) tracheal resection and reconstruction 8) a ruptured thoraco-abdominal aneurysm with spinal cooling and draining.... the list goes on... and on...

CRNA training is adequate to provide safe anesthesia in most settings...

I wasn't trying to state that we do perform all of the same cases. I understand the difference and the quality of your education. I was just hoping that others would realize that we do get a quality education ourselves. But I can see from the post after yours that the riff will probably never close because of these kinds of poor attitudes. I can't imagine working with or for someone with an attitude like the ones given on some of these posts. As a nurse I had aides and ancillary staff that I worked with. I would never have treated them as second class citizens because they chose a different profession. What a hostile work environment that would be. I guess more education doesn't necessarily lead to more class. I know my role and I enjoy it. That doesn't ever mean I would work with or for someone who acted this way towards me or my other co-workers. Guess I will keep that in mind when I graduate and look for work. I appreciate those of you who do want to work as a team though.

 

[Tenesma]

ravanbj

your postings reek of immaturity - do you talk like this outloud when you aren't hiding behind an avatar?

I have never heard Ob/Gyns talk about midwives, FPs talk about NPs, CT-surgeons talk about PAs the way you talk about CRNAs... very demeaning and very sad

 

[gaseous]

Originally posted by Tenesma
ravanbj

your postings reek of immaturity - do you talk like this outloud when you aren't hiding behind an avatar?

I have never heard Ob/Gyns talk about midwives, FPs talk about NPs, CT-surgeons talk about PAs the way you talk about CRNAs... very demeaning and very sad

Well Said.

 

[kmiska]

CougRN, do yourself a favor and don't waste your breath. You'll feel much better for it. I think you'll find in real life settings (or maybe you already know) that most people don't share the ideaology of ravanbj. Thank god. I don't think that kind of attitude lasts too long, people can usually smell an a**hole from a mile away, and usually don't tolerate it.

Also, to the person who said that they could count the number of MAC cases they did on one hand....is that supposed to be a good thing. I heard that "any monkey can put in an airway, and pass some gas, the true art of anesthesia lies in MAC cases" I'm paraphrasing an MDA.

 

[Tenesma]

the art of anesthesia.... now that is a good topic... what is the art of anesthesia?

is it timing a wake-up for the last stitch?
is it deciding when or when not to cancel a case?
is it choosing the right anesthetic plan for the right patient for the right surgery?

i don't know the right answer.... but i know some amazing role models who practice it like an art

 

[ravanbj]

I agree with you completely. Nice to hear that there are others with a realistic understanding. Although I have always had respect for everyone I work with at ALL levels, I simply have become tired of hearing all the CRNAs strut around the hospital with such attitude. I have observed CRNAs treat other NURSES as second class citizens, there own colleagues!!!! CRNAs I have worked with have an arrogant attitude that has made me take a stance in support of MDAs, nto CRNAs. Why do MDAs always get blamed for being arrogran and are always expected to be team players, when I see CRNAs acting hostil towards MDAs all the time. A Surgical PA would never dare act like that towards a surgeon. I agree that becoming a CRNA is not easy, but please do not even compare it to becoming an MDA. That's like comparing the NFL to college football, they both play the game, but at substantially different levels!!!!

 

[kmiska]

You guys are pretty funny...it's like your lips are moving (or hands are typing) but nothing of consequence comes out. You just go around in circles and pad your egos. From what I've read no one here has tried to prove that MDA=CRNA, but somehow, you guys feel like you need to prove that to yourselves.

I seriously doubt that ONLY CRNAs are snooty to others. It happens at every level. Except of course no one (except CRNAs) talk back to surgeon's because they don't dare (??WTF)...wait that must be the crack talking. Anyone who acts like an idiot deserves a talkin' to....even if they're the "boss"...no one should hold themselves above. No one is superior even though they go to school for eons...I certainly am not superior even though I went to school for 11 years (actually some people may look on that as stupid).
I should show this thread to some non-medical people...that should make them good and scared next time they have to be anesthetized (not that they're already not).

BTW, Tenesma, I think at some point any advanced practice becomes an art. I thinks it's the time when things are done from experience to some level by feel...

 

[ICU RN since83]

Never surprising, given the culture of "nurses eating their young". which I think is composed by equal parts of simple bad temper, mean-spiritedness and intellectual laziness, plus the fact that nurses of all stripes and levels of merit get crapped on (frequently) by physicians. Nurses, as do other troop primates, then look around for someone lower on the ladder to crap on. Doesn't anybody else watch the baboons on National Geographic?

As to the main point of the thread: I've worked with any number of nurses who've gone on to anesthesia, and I don't think any of them would argue that they should be put in charge of any part of one of the complex situations listed above in this thread.

And Ravanbj - you're not doing my case.

 

[KMcHugh]

Right off, let me say forgive me for what undoubtedly will be a long post. Stick with me, though, because I?m probably going to say things that will at least make you think.

Next, to dispose of a short subject: Ravenbj, you are in for a long haul. You have SO much to learn about CRNA?s. $100K ain?t the limit. Anymore, its pretty much the basement. I started out of school making $100K, and now earn considerably more than that. As to CRNA?s being your personal monkeys, you are in for a real shock. That?s OK, you?ll learn after you start medical school. Right now, it?s a power trip for you, and most adolescents go through that. And if the primary concern you and gasman have is whether or not CRNA?s are allowed in the physician lounge (they have been at every institution where I worked), well, starting residency will take the wind out of your sails.

On to more serious matters. I too take exception to the idea that a nurse can become a CRNA by taking a ?few night classes.? It is considerably more difficult than that. One of my primary gripes here is the prejudice many of you exhibit in your references to how a nurse becomes a CRNA. YOU have received a medical education, while CRNA?s merely ?attend training.? There is a subtle, yet profound difference between education and training. One involves expansion of knowledge and learning to apply that new knowledge, while the other implies learning physical skills by rote. I didn?t learn anything by rote. I am not trained, I am educated. And for me, and perhaps most CRNA?s, this is the real crux of the matter. It is a matter of respect. I respect MDA?s, even the boneheaded ones, because they made it through medical school and residency, neither of which is a cakewalk. But apparently, by virtue of that and that alone, you feel that you own no respect to any CRNA, regardless of the difficulties they faced in choosing the path they took. This lack of respect is probably the single greatest impediment to better relations between MDA?s and CRNA?s. And I recognize that it goes both ways. There are CRNA?s who don?t seem to respect MDA?s. That?s equally disrespectful.

Having said all that, allow me to say this. Perhaps it is my military background, perhaps it was just my upbringing, but professionalism is very important to me. One of the benchmarks of a professional is the recognition of one?s own limitations. Let me say this clearly, and for the record. I do not believe, even secretly, that CRNA = MDA. There are distinct differences in education, and many of these differences are reflected in our scopes of practice. There are things MDA?s do every day that are not within a CRNA?s scope of practice. I can walk into an operating room and provide a good, safe anesthetic to a patient for almost any surgery. I can walk into an OB suite, and provide safe, reliable OB anesthesia. I can even provide some chronic pain management services. But, if a patient needs, for example, a CESB under fluroscopy, then I help the patient?s primary care provider to find an anesthesiologist with the experience to perform that procedure. I?ve seen the procedure done, I understand the implications of the procedure. Doesn?t mean I should try to do it just to prove something. That?s unprofessional.

The point is that I have an education that was very good, and very focused. I provide anesthesia to patients, and I do it very well. But I understand my limitations. MDA?s, by virtue of having attended medical school, have a broader education, and are better prepared for some of the more esoteric, less common comorbid conditions that patients may present with. However, that does not mean I am merely a trained anesthesia monkey, able only to do appys on ASA I patients. Not only have I done anesthesia for craniotomies for aneurysms, not only have I done anesthesia for ASA IV patients having quadruple bypass with an AVR, I have actually been placed in rooms to supervise residents doing these anesthetics. Why? Not because I?m better educated, but because I was more experienced with these cases.

So, where does that leave us? First, I think it leaves us needing to recognize a few things. We need to recognize that both sides have some work to do in the area of respecting their colleagues. Tenesma was right. Some of those procedures he listed need the services of an MDA (though frequently, those kinds of cases are done by two anesthesia providers, usually an MDA and a CRNA working together.) But that does not mean CRNA?s aren?t capable, competent anesthesia providers. Some of you have hooked onto the numbers listed in CougRN?s post, but remember, those numbers are the absolute minimums required by the AANA to graduate, and last I heard, they were thinking of raising some of these minimums. I don?t know of anyone who finished any school with only 600 cases. I attended a school that shorter than many, only 24 months. At the end of that time, I had provided anesthesia for well over 1000 cases (don?t have the actual numbers here in front of me). I had done over 100 open heart procedures, which more than one MDA commented was more than they did during the course of their residency. I placed at least 50 central lines, and lost count of the number of arterial lines I placed. My program provided me with a good education, and the experience to back it up. Does that mean I was ready to be fully independent on graduation? No, but then most MDA?s are not ready to be fully independent on completion of residency either. There is still, for both, a period of seasoning that is needed.

I have, in my short career as a CRNA, had the good fortune to work with some very fine, very competent MDA?s. To be truthful, many of these people taught me more about the art and science of anesthesia than I could possibly relate here. I respect them, and I owe them.

Bottom line is that it is time for MDA?s and CRNA?s to put aside the petty bickering. Its time for CRNA?s to stop claiming to be the equal of any MDA. Its time for MDA?s to stop claiming that CRNA?s are not worthy to pour the MDA?s coffee. Its time to stop teaching the kids like Ravenbj that CRNA's are the MDA's bi***es. Right now, anesthesia providers are retiring faster than CRNA programs and MDA residencies can turn them out, and the number of surgeries is on the rise. We need to find ways to turn these trends around before we all are forced to work 80 hours a week routinely. Part of the reason I left where I was to go to a more rural hospital was that I was tired of never seeing my family, tired of never leaving the hospital (yes, Virginia, CRNA?s are working those long hours, and taking call right alongside of the MDA?s). I love what I do, but I also love having time where I don?t have to do it. That?s why both sides need to start seeing the other side as allies, rather than adversaries.

Kevin McHugh, CRNA

 

[Gator05]

Kevin, great post. I've worked with some excellent, military-trained CRNA's who were extremely professional and competent. That goes for a number of mid-level practitioners I've worked with in general, whether they be NNPs or nurse-midwives of PA's working in various units.

I find it interesting that I never hear a NNP or nurse midwife or PA stating they can do "anything an MD can". Actually, many of them state they were quite humbled by the pathology, pathophysiology and decision-making skills they received during their graduate coursework. They often voice, unprompted, how they underestimated the thought processes that went into the decisions physicians make. Yet I tire of younger CRNA's (inevitably, it's the younger ones or students; the older ones seem to have the self-confidence of someone who's earned it) who blab about doing anything an MD can, without ever participating in the decision-making process an MD relies upon for effective patient care.

Now, medicine can be practiced on a simplified level via a streamlined, protocol-based method. It's just not always practiced very well this way. Think of it like this; even a 1st year med student, well-versed in the pathways of ACLS, can run your average code. But when the code takes a funky turn, and the pathway doesn't tell you what to do next, it's the medical training/education that shines through.

One of the mentors in anesthesiology at our institution waves off the CRNA/MDA issue with the opinion that their will always be a demand for ultra-capable anesthesiologists, providers whose training has truly prepared them for anything. Practitioners whose involvement with patient care begins at the moment the decision for surgery is made, and finally ends sometime near discharge; the perioperative practice of medicine.

I think it is a responsiblity of any practitioner, be they an MD, RN, or midlevel practitioner, to recognize their limits even within their scope of practice. This is a great juncture for MDA's to explore and embrace the notion of practicing perioperative medicine.

 

[CougRN]

Originally posted by The_Gas_Man
Please..........I'm sorry, but I have to reply to this idiotic statement. I always hated it when the SRNAs at my institution said they were doing their "residency"

GasMan i'm not sure how I offended you enough to claim that this was an idiotic statement. Not once have I tried to say that an SRNA's training is equal to that of an MDA. I was only trying to state that we work very hard too. I was never trying to minimize your education or training. So please don't call me an idiot. I also never stated that CRNA=MDA because I know it does not. I am not the people you have run in to that refers to myself as an MDA so please don't take your anger out on me. I was just trying to let those who do not know that we work hard for our degree also without trying to offend anyone. That was never my intent.

As for the "residency" issue. Physicians don't hold the market on being the only profession to do a residency. Did you know that hospital chaplains do a residency? Will you hold them to the same standard because they say they are doing their residency? Or speech therapists do a fellowship. Are they also not allowed to use that word because they didn't go to medical school? Yes, your residency is very very intense. Hours are unbelievable and your committment is exceptional. But other professions do have residencies and fellowships. Just a thought. No offense intended, ok!

Personally I would just like to be proud of my education without being told it's nothing because it wasn't as difficult as yours. I respect the physicians I work with and enjoy a mutual respect from them for what I do. Without each other we wouldn't be able to care for the patients. My hope is that we can all work as a team and provide excellent care. If someone wants to be a leader they need to earn the respect of others. Not by education but by respecting those they work with and working hard. As Kevin said. There is no place for any profession to treat others with disrespect whether they are RN's, CRNA's or MDA's. That only takes away the respect you may have earned. Some nurses do eat their young but I have also seen some attendings tear into an intern and that always made me question their leadership too. I hope I was able to clarify myself without offending anyone.