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CRNA v. MDA costs

Discussion in 'Anesthesiology' started by Platysma, Apr 1, 2004.

  1. Platysma

    Platysma Junior Member
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    I brought up a point in another thread that I thought was reasonable. Perhaps it's not, but I'd really be interested in what people have to say about it--

    People think that CRNAs are going to compete MDs out of jobs because they're cheaper. They look at the average salaries of a CRNA and a MDA, and since MDAs make more money, they conclude that if we had nothing but CRNAs, we'd save a lot of money.

    However, CRNA and MDA reimbursement under Medicare is EXACTLY the same. MDAs generally make more money because they can supervise multiple cases, and get reimbursed for all of them, while CRNAs can only get paid for one case at a time. However, the government's bill per case is exactly the same, the only difference being who the money goes to.


    In general, most insurance companies follow the lead of Medicare. Some companies reimburse extra 10-20% for doctor's care, but that's a relatively small change, and is not the primary reason for the difference in salaries. At worst, that extra 10-20% would go away, and we would still have essentially the status quo.

    So, CRNAs won't save the nation as a whole any money. Some CRNAs are hired by the hospital. In those cases, the hospital gets the money, so they could pay the CRNAs an arbitrarily low salary.
    So, maybe hospitals could save some money.

    However, CRNAs are allowed to independently bill for their services, and work in independent practice groups, just like doctors. Why would they want to work for the hospital and give up the billing money that they could keep for themselves?

    One last thought-- CRNAs have been legally allowed to perform anesthetics by themselves (not counting surgeon "supervision") for a long time, in all fifty states. If they really were so advantageous, why are there so many anesthesiologists in the first place? There must be some reason why hospitals in urban areas that can attract anesthesiologists ask for them instead of asking for CRNAs.
     
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  3. BassDominator

    BassDominator Senior Member
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    Just curious.... where did "MDA" come from? I've never heard anyone use this term outside the forums.
     
  4. Sveet07

    Sveet07 Junior Member

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    yeah, i've never heard of this MDA terminology outside this forum either. where did you get this from? forum?, stuff you read?, flyers?, ad?, magazines?national enquirer?!!

    if you are worried that some day anesthesiologist can't find a job because of crnas then the solution is very simple: when that day come, simply demote yourself into a nurse anesthetist and then you'll will find plenty of job, right? if you are worried that someday crnas will make more money and over take the whole market then you can do the same too, right? this is on the assumption that your theory is correct. no more worries. end of discussion ;)

    ----------------------------------------

    if you can't beat them join them
     
  5. MacGyver

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    Thats not the issue. There will always be jobs for MDAs. The real question is how much income will they make?

    CRNAs already control the majority of gas delivery for surgeries in this country (something like 65% of all gas is administered by CRNAs).

    As for the orginal post:

    What you fail to realize is that this is just the first step of the salary readjustment for MDAs and CRNAs. Sure, Medicare reimburses them the same right now, but what will happen is that Medicare will come under ENORMOUS pressure to reduce costs as baby boomers retire. When that happens, govt bureaucrats will be highly likely to select MDAs and CRNAs as the sacrificial lamb. Medicare will pay MDAs and CRNAs the same, but they will CUT reimbursement for gas more than for other fields.

    CRNAs will complain just like the MDAs. However, UNLIKE the MDAs, they wont leave the profession. CRNAs are the highest paid of the nursing jobs, and their income would have to fall by over 50% before there is competitive pressure to pursue other nursing areas. Therefore, CRNAs at large will continue to work in gas despite pay cuts. Due to this, the outcry that Medicare would face by reimbursement cuts will be substantially less than it would be otherwise if MDAs dominated gas delivery.
     
  6. hndrx1a

    hndrx1a electric medical haze
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  7. That's got to be the lamest signature I've ever seen.
     
  8. hndrx1a

    hndrx1a electric medical haze
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    :rolleyes: "sarcastic""roll eyes"
     
  9. Swaydaa

    Swaydaa Senior Member
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    It's actually one of my favoritesssss!
     
  10. :laugh: I was talking about Mac Guyver's sig. Not hating, just read the whole thing and had to chime in there...
     
  11. Platysma

    Platysma Junior Member
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    Yes, but the vast majority are supervised by anesthesiologists. I believe less than 35% of all anesthetics in this country involve CRNAs without MDA supervision. And, mostly these occur in rural areas. Any hospital that is capable of attracting an anesthesiologist group gets one. If CRNA groups were so desirable, then why don't most hospitals contract with them?

    Maybe. But I think people need to realize is that there isn't right now any pressure to hire a CRNA over an MDA just because CRNAs make less money. So the idea that CRNAs are going to drive MDAs out of business is not reasonable. Yet this is what 90% of the debates I see on this board about CRNAs focus on.

    As for reimbursements, they may fall (just like they have in a lot of specialties). However, the doctor and anesthesiology lobby will put up just as big a fight as the nurses. Although more med students may choose not to enter the field, the doctors in the field are going to fight just as bitterly to keep their reimbursements up. Likewise, the CRNAs are going to fight just as hard to keep reimbursements up even though they would be happy with less.

    Also, there is going to be huge demand for anesthesia providers in the future- there is currently a big shortfall. Remember- to be a CRNA, you have to first be a nurse, then do 18 months of critical care, then go to CRNA school. There is already a major shortage of nurses, even with the increased demand for CRNAs. I don't think that there will be so many CRNAs that the field of medical anesthesiology will go extinct. Even if you cut reimbursements by half, it still pays better than FP and is far more fun.
     
  12. voltron

    voltron Member
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    Guys, please ignore MacGyver. He is apparently psychic, so there's really no point in arguing with someone that powerful ayways. Hey Mac, who's gonna win the Kentucky derby this year, I got some loans I need to start paying back.
     
  13. BassDominator

    BassDominator Senior Member
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    In an academic setting, less than 5% of anesthesia is delivered by CRNAs. It's always routine cases with very close supervision. Passing gas is a dangerous business, hospitals know this, and any hospital worth it's salt is not going to let CRNAs handle anything unsupervised or too complicated.

    I've known a lot of great CRNAs, I usually can't tell they're not MDs unless someone tells me, I would have no problem letting a CRNA put me out for something routine.... but anybody who thinks CRNAs will ever come close to replacing MDs has absolutely no clue what they are doing.

    I'm not trying to start a flame war here. I have tremendous respect and appreciation of CRNAs. The ones I know laugh when I ask them if they feel like they are competing with MDs. Both MDs and CRNAs play equally important, but nevertheless very different roles. Even still, the demand is so great and will remain great for many years, that the two will never truly be in competition.
     
  14. MacGyver

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    thats an incredibly short-sighted vision, and thats what got MDAs in this mess to begin with.

    The logic that "we should just concede all the routine stuff to CRNAs" is a bad move. Essentially, it forces MDAs to do only the "complex" cases. As you allow the CRNAs to "take over" bread and butter cases, the definition of "complex" cases will continuously shift more and more towards what CRNAs do, and force MDAs to accept decreasing market share.

    Once MDAs start losing market share, their lobbying efforts with Congress and state legislatures will lose thier potency. Conversely, as CRNAs take up increasing market share, their lobby will become more powerful. Eventually, a critical mass will be reached where Congress/legislatures no longer listen to MDAs and devote their full attention to CRNAs. Thats a recipe for disaster.
     
  15. PCOM_Rocks

    PCOM_Rocks Member
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    Mostly true but I highly doubt that nurses will ever have more clout than physicians.
     
  16. Krafty

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    :sleep:

    Man, why do people still answer to Gyver's rants? I just love modest predictions on scant evidence. Hey Mac....how bout a career as a CRPP [Certified Registered Political Pundit]...CNN Crossfire here he comes!
     
  17. powermd

    Physician Lifetime Donor Classifieds Approved 15+ Year Member

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    "The question is, 'Does MACGUYVER have an INFERIORITY complex?' Which makes me wonder if this... MD/PHD STUDENT... has any idea how WIRED TO THE INTERNET one must be to be REGISTER ON SDN. If you have the vaguest clue as to how PERSISTENTLY ANNOYING someone has to be TO POST MEANINGLESS INFLAMMATORY DRIVEL IN THESE FORUMS. I DON'T have an M.D. from Harvard. I AM NOT board certified in cardio-thoracic medicine and trauma surgery. I have NEVER been awarded citations from ANY medical boards in New England, and I am ALWAYS sick at sea. So I ask you: When someone goes in to that chapel and they fall on their knees and they pray to God that I'LL STOP POSTING ABOUT THE MINIMAL THREAT OF CRNAS, or that I'LL LEAVE ALONE THE FAMILY DOCS I FEEL ARE THREATENED BY NPS, or that I'LL CONSIDER NEVER POSTING TO THE OB/GYN FORUM ABOUT THE IMPENDING MID-WIFE THREAT, who do you think they're praying to? Now, you go ahead and read your MILLER... VENTDEPENDANT, and you go to your RESIDENCY PROGRAM, and with any luck you might BECOME AN ANESTHESIOLOGIST, but if you're looking for A PARANOID MANIAC, He was in SDN FORUMS / GRADUATE MEDICAL FORUMS [MD/DO] / ANESTHESIOLOGY on APRIL seventeenth, and He doesn't like to be second guessed. You ask me if I have AN INFERIORITY complex? Let me tell you something. I am A TOTAL F***ING PSYCHO." - MACGUYVER as DR. TROLL, from the SDN FORUM ANESTHESIOLOGY.
     
  18. BassDominator

    BassDominator Senior Member
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  19. Kalel

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    Sorry if this has already been addressed in this thread already (difficult to read through all of the 'ranting' ;) ), but CRNA's are not paid less on a per-case basis then MD-A's (and I have heard that term being used to describe anesthesiologists before). I've heard that it's illegal for insurance companies to pay less for the same service just based on the provider's degree. CRNA's do end up getting paid less the MD-A's though, because they are usually required to work under MD-A's who take a portion of their reimburement as payment for supervision. At some hospitals where I have worked, the situation has gotten kind of silly in my opinion, with MD-A's leaving for 3-4 hr coffee breaks while "supervising" 3-4 CRNA's. I've heard that MD-A's have kind of forced themselves to rotate through OR time so that they don't lose their skills because they spend so much time supervising. They have been doing studies looking at outcomes with care under MD-A's vs CRNA's and my understanding is that these studies were not able to show any difference in anesthesia outcome. There are much more forces at work here then just demonstrating that one specialist is as competent as another though. The fact is that there is currently a shortage that is only worsening of MD-A's and CRNA's secondary to the aging population and the increasing number of surgeries that are being done. And it's not like there is some sort of endless supply of CRNA's that are waiting on the sideline to invade your guy's territory, there is actually a real shortage of regular nurses out there which means that there is that incentive for people not to increase the number of CRNA's being trained. Nursing schools are also having trouble finding the faculty to run these advanced degree or even regular degree programs because the salary in private practice is so lucrative for them compared to academics. So anyways, I think that all of this spells out to a healthy demand for MD-A's and CRNA's in the future with longer coffee breaks for you MD-A's as more CRNA's are eventually trained.
     
  20. BeefyRedEye

    BeefyRedEye Member
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    :laugh: :laugh: :laugh: :laugh: :laugh: That was great!!!!
     
  21. MacGyver

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    powermd, you win my "karma *****" award for today.
     
  22. emedpa

    emedpa GlobalDoc
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    bingo. hit the nail right on the head!
     
  23. juddson

    juddson 3K Member
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    You people are children. Engage MacGyver on the merits. You post, he replies. You post, he replies. There's nothin trollish about his responses. They seem well thought out to me. And on point.

    Judd
     
  24. powermd

    Physician Lifetime Donor Classifieds Approved 15+ Year Member

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    Self-rightgeousness is always appreciated here!
    Apparently you've been around for two years with 500+ posts, but you don't know Mac very well, do you? Mac does not respond to reason, so I see no need to continue being reasonable with him. I've read his posts for more than a year now, and responded rationally many times. I've also read dozens of other well-considered replies to his nonsense. Here's the thing: MacGuyver does not respond to reasonable criticisms of his position. Earlier this year Tenesma, I believe, questioned him about some statistics he posted (just asking for the source), and as soon as he did- Mac disappeared! In other threads Mac will typically ignore the good criticisms, but respond to the weak ones, and restate his position over and over. Whenver Mac is questioned about his motivation to slam mid-level practitioners, he never responds. What the f*** is that? Any normal member of this forum would at least respond with something when asked why we care about an issue. Most of us see Mac as an obsessive nut. His passion (paranoia?) for his issue, and unwillingness to listen to reason, combined with the fact that he either starts inflammatory threads (with subject lines seemingly intended to roil people), or hijacks existing threads with the same, as well as occasionally lying about statistics, give him troll-like character.

    Add to this his unwillingness to ever discuss his painfully long half-page signature, and it's content (a guy jerking off over his own arrogance), and you've got one seriously weird mofo.
     
  25. BassDominator

    BassDominator Senior Member
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    Off topic: powermd, you are going to love it at LIJ. Very sweet prelim spot.
     
  26. zenman

    zenman Senior Member
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    When I was at the Texas Heart Institute in the 80s, CRNA's were doing heart cases. I didn't see much supervision by MDAs.
     
  27. Tenesma

    Tenesma Senior Member
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    a few points:

    1) CRNAs do 65% of all anesthetic cases in the country: this is patently misleading.... they do provide a lot of rural/office-based unsupervised care. However, what is not being taken into account is that those 65% of cases are actually for the most part supervised by a physician (primarily an anesthesiologist). It is like saying that NPs do 60% of all floor care in the country, when in fact they are supervised for the most part.

    2) medicare doesn't reimburse equally - this is a commonly perpetuated misunderstanding of medicare billing. Anesthesia is billed by units, regardless of who provides the anesthetic. So let's say a lap chole is about 6 units - which hypothetically comes to 6x$30=180 bucks. the anesthesiologist will get 180 dollars. the CRNA (without anesthesia supervision) will 85% of the 180 dollars and the surgeon/endoscopist/whoever gets the other 15% of the 180 dollars. This discrepancy is based on the fact that there needs to be a physician responsible for prescription (ie: if you look at a bag of lactated Ringer's it says: "physican prescription"). So as far as insurance companies go there is a discrepancy for reimbursement, however CRNAs can make up for this in some states by independently billing what ever they want of the patient.

    3) zenman: texas heart institute --- i have a few friends there, and I can assure you that the "few" CRNAs who come and go, do only the simplest of cases and are always supervised by an MD. You might have seen them do a consent, or maybe dropping off a stable/easy patient in the ICU, but that is about the extent of their involvement. I am not saying that CRNAs can't do some cardiac anesthesia, but not at texas heart - if not for one very big reason, there are way too many MDs around to even make room for a CRNA
     
  28. zenman

    zenman Senior Member
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    Tenesma, it was 1979, not 80s. I was a pump tech student and the CRNA was there the entire time(s) I was in the room doing open hearts. MD dropped in every so often. Could certainly be different now. That place is (or was) a factory line.
     
  29. UTSouthwestern

    UTSouthwestern 1K Member
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    As a followup on THI, I spoke with another resident at THI and he states that there are no CRNA's doing hearts at TMC in general.
     
  30. racer

    racer New Member

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    Just a couple of quick comments. After quite a few years, I don't think anyone here needs to worry about their jobs security or their salary anytime soon. Next, our CRNA's routinely perform the cardiothoracic cases in our large (650 beds) teaching hospital (no, we don't have an anesthesia residency)with as little or as much supervision as they need. Some of them have been doing this for 25+ years. Where I moonlight, cardiothoracic is performed by an outside group who employs thier own CRNA's and only CRNA's. Don't go getting all turf crazy over these things. CRNA's aren't going away and neither are we. Happy times! Spend your time worrying about more useful things.
     
  31. gtb

    gtb Member
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    At the University of Colorado, CRNAs are occassionally doing the gas on transplants. Yes, of course they are supervised by anesthesiologists, but the case is sometimes a CRNA from induction to extubation. This has actually caused a bit of friction with the residents because the CRNAs were getting more of the complicated cases while the residents were getting the lap chole on a 25-year-old hardbody. I suppose this is more of a scheduling issue instead of a CRNA vs. MD battle.

     
  32. Sleepfairy

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    I trained at Maryland Shock Trauma (Cowley) . It is well known that CRNA's are the intergral and primary clinicians on ALL trauma as well as their anesthetic. Let me remind you that MDA's have only come along after WWII and certainly not contributed anything to the front lines in battle. Anesthesia is the practice of nursing and if you wish to consider it the practice of medicine, you have that right since MDs practice medicine when giving anesthesia. Regardless we are both held to the same standard of care and we should both be advocates for patient safety and quit squabbeling over $$$$ and turf control. CRNA's are here to stay, get over it and understand their will and always be good and bad CRNA's as well as MDA's. Take your GOD complex somewhere else, we all know how your trained, and have trained with you in shared anesthesia residency programs. We have worked with you in ICUs, ED, and OR"s. A good anesthetist boils down to experience, training, compassion, vigilence, experience and experience...this equates to a RN !! And guess what ? I also have 20+ years of education as well as over 10 years of experience in medicine/nursing so dont pull the education card on me or ALL the experience and knowledge you get in medical school not having worked 1 day in your life !:thumbup:
     
  33. Tenesma

    Tenesma Senior Member
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    sleepfairy ... what the??? besides your obvious insecurities....

    1) it is NOT well known that CRNAs are the primary clinicians on ALL trauma at Cowley... that is a load of crap - And that is after I spoke with Dutton who is in charge at Cowley.

    2) not contributed anything to the front lines of battle... did CRNAs develop pulse oximetry, blood gas analysis, end-tidal CO2 monitoring, multi-modal ventilators, ANY of the volatiles???, ANY of the drugs??? .. the list goes on. And the argument that nurses provided ether under the direction of surgeons in emergent cases with expected high mortalities, and thus claiming ownership is as absurd as saying that Barbers were the first to perform surgery, and therefore Barbers should be considered the authority on anything surgery-related... yeah whatever...

    3) we are NOT held to the same standard of care, since in the courts of law we are held to the standard of care of our peers based on our training (thus in court, the defense/prosecution will hire MDs as expert witnesses in cases against or for MDs)

    4) you haven't trained "with" us in "shared" anesthesia programs... you may have been a SRNA at a hospital where there was a residency... that is all

    5) this belief, that because CRNAs do cardiac cases or transplant cases on their own, all of a sudden proves a point is absolutely bogus.... I have seen CRNAs do cardiac cases and transplant cases, and basically this is what they do: manage the airway, monitor, record - and any big decision is made by the surgeon...


    so for all future posters on this issue - beyond economic turf control there is no competition between MDs and CRNAs because it just wouldn't be a fair competition. So how about you go to medical school, do an anesthesia residency (like 2 CRNAs I know) and then you can tell me what my education should or should not represent to others...

    this is just getting boring
     
  34. Sleepfairy

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    Like I said I Know what your education and training is and your just a CRNA wantabee what other reason would you get into a profession that is well defined and respected by surgeons ? Sounds like being a lounge lizard fits you to a tee because you dont have enough insight or information to make a educated decison ! I laugh at your Dutton quote...why dont you get into the real world and when your panties become wet because you cant get a airway on a patient with a crushed trachea dont come crying for help from the incompetent CRNA. Try doing some research on the subject before you open your mouth as well..CRNA's are on the front line in every war while the MDA's sit back at the base hiding behind the anesthesia machine. Surgeon make any important decision in regards to the patients anesthetic ? Hmm I doubt that, thats called vicarious liability, but must happen to you huh ? sorry bout that :( Enough said ! :laugh:
     
  35. jwk

    jwk CAA, ASA-PAC Contributor
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    Obviously you skipped out on English class during all that 20+ years of education you claim you have. BTW, are you starting with nursery school?
    K-12 + BSN + CRNA = 19 years.
     
  36. Tenesma

    Tenesma Senior Member
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    sleepy:

    you are right about CRNAs being on the front line of the war --- primarily because MDs choose not to be. Especially if they can make more money in private practice.... by the way, taking care of a previously healthy trauma patient is not all that difficult, since their care primarily revolves around securing an airway, having primary surgical repair and fluid management...

    I am in the real world.... and i don't call CRNAs for help, they actually call me for help.... and by the way I have performed quite a few tracheostomies (about 25 - most were percutaneous), so if there is a crushed trachea who do you think is going to manage it if there is no surgeon around/available... you or me?

    Sleepy.... go home before your lame postings make me get sleepy
     
  37. apma77

    apma77 Senior Member
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    another stupid CRNA vs. MDA thread..some1 please put this lil bitc# out of its misery!
     
  38. jwk

    jwk CAA, ASA-PAC Contributor
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    Correct me if I'm wrong - you're an incoming CA-1? You have a lot to learn about the CRNA-MDA (and sometimes AA) debate. You ought to learn why the debate is important to you and your colleagues, because obviously you don't have a clue. Sure some of these threads get a little long-winded or repetitive, but there is a constant stream of new people coming into this forum who haven't heard all the previous rantings and ravings (including yours).
     
  39. bestiller

    bestiller Member
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    I don't think it's stupid to debate but, I do think both sides (MDs & CRNAs) spend too much time and resources fighting this "war". Imagine if the ASA & the ANAA combined their lobbying efforts for anesthesia practice & reimbursement rather than spend $millions trying to discredit the other. Research how much PAC $ each side has. Neither side is going away! Each will contiue to make good living. The opt-out issue will plateau just as the AA issue will. Even if a state "opts-out" do you think the medical staff board at your local metro hospital w/ all MDs sitting on the medical staff board are going to hire all CRNAs for their anesthesia coverage? Get real! Even if a state legalizes AAs (which many aren't) it would take 20 years to make a dent in the supply b/c their aren't enough AAs and their are only 2 schools w/ 1 more coming on line to produce them, this is a vain move by the ASA b/c AAs are already suing in Ohio for expanding scope of practice. Any time you lessen qualifications it cheapens your profession! MDAs have forgotten that they are in the anesthesia business not the "supervision" business. You don't see a surgeon supervising 4 cases while a PA does the surgeries. MDAs do have their place and need and CRNAs must realize that. Both sides knew how the business worked prior to entering the profession and now each side has members mad about how the business works!
     
  40. gaseous

    gaseous Senior Member
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    Then they should do a search for the topic. There are hundreds of threads just like this one. Maybe I will care more next year when I start my CA1 year, but I doubt seriously I won't get a sweet job after residency, make more money than I can spend and live happily ever after!
     
  41. Lonestar

    Lonestar Senior Member
    10+ Year Member

    Joined:
    Jul 12, 2002
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    That's right gaseous, tell them how it is. Happiness is key to healthy living. And I plan on living healthy for a long, long time. Now, granted there will be good days and bad days in the wonderful field of anesthesiology; the good days certainly outnumber the bad ones. As a good teacher of mine always says "sometimes you just got to let it roll of your back." Just live and let live.
     

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