Crna versus md Anesthesia

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europeman

Trauma Surgeon / Intensivist
15+ Year Member
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Just curious from the surgeons' perspective, what are your thoughts on complete, independent anesthesia practice by crna's?

Seems like they are gaining more and more independence (depends on state, facility, etc).

As a surgeon, this is a real concern for me.

I'm surprised the American college of surgeons hasn't addressed this issue.
 
I refuse to operate at facilities that are only staffed by CRNAs. I live in a large city where these decisions are made not because of a shortage of excellent anesthesiologists but rather as a cost saving measure at the expense of the patient. These hospitals are also unable to show the surgeons any proof that we are not the supervising physician during the case should some **** go down. Our physician colleagues deserve our support against this war on their livelihood as do our patients.
 
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Yeah I totally agree. Why aren't surgeons part of this discussion? It seems everywhere it's debated and such the anesthesia MDs are on their own.
 
Yeah I totally agree. Why aren't surgeons part of this discussion? It seems everywhere it's debated and such the anesthesia MDs are on their own.
Lots of reasons.

1) surgeons figure its "not my business/dogfight"
2) surgeons too lazy/busy to do something about it; one of my partners falls into this category. She works primarily at a hospital which only has CRNAs. She doesn't like it but doesn't want to switch where she operates and doesn't have time/interest to put up a fight.
3) surgeons too arrogant to think that something like CRNA infiltration affects them; sooner or later, IMHO, someone will suggest having non-surgical residency trained "operators" performing simple cases.

We only have ourselves to blame for not taking a stand and for allowing our colleagues behind the drape to be treated in such a fashion. Who will they come for next?
 
I refuse to operate at facilities that are only staffed by CRNAs. I live in a large city where these decisions are made not because of a shortage of excellent anesthesiologists but rather as a cost saving measure at the expense of the patient. These hospitals are also unable to show the surgeons any proof that we are not the supervising physician during the case should some **** go down. Our physician colleagues deserve our support against this war on their livelihood as do our patients.

My understanding is that if you are not in a state that allows crna's to work without supervision then the surgeon is considered the supervising provider if no anesthesiologist is present. I don't see how that hospital can claim anything different. Why would any surgeon agree to post an elective case there?
 
My understanding is that if you are not in a state that allows crna's to work without supervision then the surgeon is considered the supervising provider if no anesthesiologist is present.

That is true.

I don't see how that hospital can claim anything different.

They (at least in my case) aren't claiming that; they just plead ignorance. "Oh I'm not sure, we'll get back to you on that, etc." I feel like they need to provide written documentation to the surgeons about that. Typically when hospitals make a decision that they know will be unpopular, they "disclose" it in some sort of fashion that virtually guarantees that not everyone will know about it.

Why would any surgeon agree to post an elective case there?

1) because they don't know they're the supervising provider
2) because the patients prefer that hospital (we have a lot of older patients here who refuse to drive any distance farther than they have to and of course, you know how demanding breast patients are about everything)
3) because the surgeon prefers that hospital - just got off (literally) the phone with one of my partners (the one mentioned above). She was working at my usual hospital today and called to complain (because of course we do things different so it didn't flow as easily) to me. She has a nice system at the hospital with the CRNAs and it makes her life easier, so she just ignores the issue at the head of the bed.
 
That is true.



They (at least in my case) aren't claiming that; they just plead ignorance. "Oh I'm not sure, we'll get back to you on that, etc." I feel like they need to provide written documentation to the surgeons about that. Typically when hospitals make a decision that they know will be unpopular, they "disclose" it in some sort of fashion that virtually guarantees that not everyone will know about it.



1) because they don't know they're the supervising provider
2) because the patients prefer that hospital (we have a lot of older patients here who refuse to drive any distance farther than they have to and of course, you know how demanding breast patients are about everything)
3) because the surgeon prefers that hospital - just got off (literally) the phone with one of my partners (the one mentioned above). She was working at my usual hospital today and called to complain (because of course we do things different so it didn't flow as easily) to me. She has a nice system at the hospital with the CRNAs and it makes her life easier, so she just ignores the issue at the head of the bed.

Does the hospital refuse to credential anesthesiologists at the facility? If so there might be some legal recourse for the area anesthesiologists. If they do credential MD's what prevents surgeons from calling an anesthesiologist directly for cases? I'm sure there will be patients who want to have surgery at only this hospital but I wonder just how many will continue to insist on that when you tell them that the hospital forces you to use only nurses to put them to sleep to increase profits.
 
Does the hospital refuse to credential anesthesiologists at the facility? If so there might be some legal recourse for the area anesthesiologists. If they do credential MD's what prevents surgeons from calling an anesthesiologist directly for cases? I'm sure there will be patients who want to have surgery at only this hospital but I wonder just how many will continue to insist on that when you tell them that the hospital forces you to use only nurses to put them to sleep to increase profits.
At many community hospitals there is "house" anesthesia and outside groups may or may not be allowed to apply depending on hospital policy. Similar to an open vs closed ICU.

The "house" group is CRNAs at this hospital but I understand you can request an MD/DO. I also understand they are never available (ie because they are doing the heart cases) but will ask my partner tomorrow. I am curious if other gas groups are allowed to apply for privileges there or if it's closed. I'm not sure they're interested because it's a dense Medicare population out in Sun City and the reimbursement for CMS anesthesia services is a money loser. They want my high paying cash or private insured patients.

Patients are concerned IF they know. Because I don't go to that particular hospital when patients request to have their surgery there, it's definitely one of the things I mention to them as to why I don't operate there. Most patients are appalled.

My partner is not one to create waves; she has no motivation to change things there but it's only served to hurt her because since none of the rest of the partners go there we can't take call on her patients. She definitely doesn't tell them about the CRNAs.
 
as the government and other payers look to shrink costs this will be more and more the norm. I'm too ambivalent to look but are there any stats that back up that CRNA only anesthesia is worse than MD anesthesia? I imagine the payers have access to such data and would feel confident there is no appreciable difference or they wouldn't allow it. Too much liability on their end if there were major documented differences in care. I love my anesthesia colleagues and like knowing they are available but for most cases a CRNA can take care of the patient just fine. MD-A is just there when things deteriorate - which is rare for most cases.
 
In private practice I haven't had any issues with CRNA's and I tend to operate on some sick folks. But they are all supervised. Even if the data shows that CRNA only is no worse than supervised anesthesia, which would surprise me in the emergent surgery population, as a surgeon I wouldn't want to carry the liability of serving as the supervisor. Also, I don't know if my malpractice insurance provider would have an issue with that.
 
With regards to the question about whether data demonstrates a difference between anesthesia provided by CRNA vs MD, in my opinion we can't say with any certainty until we compare completely unsupervised CRNA-provided anesthesia (NO backup whatsoever) to outcomes when MDs are at the head of the bed. As many have said before me, the confounder in past studies has been undocumented "near misses", in which a CRNA is bailed out of a complication by an MD supervisor. It is widely accepted the majority of these go undocumented, and it stands to reason this- at least in part- is responsible for the comparably low complication rates.
 
I'm very glad now and again to have my MD-A colleagues around. I'm not advocating for a CRNA only practice with no oversight and I certainly have no interest in being their "supervisor" (though I am more confident with the airway than most other surgical folks). I'm just not sure we should act like CRNA's are practicing sub-standard care. For a lot of things, it just isn't that hard to give modern anesthesia.
 
I'm very glad now and again to have my MD-A colleagues around. I'm not advocating for a CRNA only practice with no oversight and I certainly have no interest in being their "supervisor" (though I am more confident with the airway than most other surgical folks). I'm just not sure we should act like CRNA's are practicing sub-standard care. For a lot of things, it just isn't that hard to give modern anesthesia.

And I'm not arguing that.

My cases are generally low risk ones performed in healthy patients. These are likely appropriately managed by a CRNA. The research they provide is weak with so many confounders as to be meaningless. The government, hospitals and lay public doesn't see that and therefore, think there is equivalence. Interesting however that when you operate on a nurse, they always want an MD/DO-A and not a CRNA.

My concern is:

1) the cases that are not; even "healthy low risk" patients sometimes code on the table
2) if we don't ally ourselves with our anesthesia colleagues, in recognizing their superior fund of knowledge and skills, and support their cause then who will help us when someone decides that all breast biopsies are to be done by an RN, or trachs, or skin cancer excisions or…

Surgeons have been proven in the past to be too egocentric to think that anyone could tell them what to do, or to change their practice. So while I agree that a CRNA could do the vast majority of my cases and provide good care, I fear for the future of the specialty of anesthesia, family practice, and by extension, surgery.
 
I haven't gone deeply into the methods of the studies, but a few things that pop out to me. (1) They are looking at pre-selected low risk patients. One could argue that this is the realm that most CRNAs practice, but once you remove supervision requirements there is no reason they won't branch out into higher risk cases. (2) Because of the low risk patient population, the expected adverse event rate (e.g. otherwise healthy patient codes on the table) is extremely low, meaning that to show any significant difference between MD-A and CRNAs, the study would have to be absolutely massive. (3) Studies don't account for near-misses as discussed above.
 
And I'm not arguing that.

My cases are generally low risk ones performed in healthy patients. These are likely appropriately managed by a CRNA. The research they provide is weak with so many confounders as to be meaningless. The government, hospitals and lay public doesn't see that and therefore, think there is equivalence. Interesting however that when you operate on a nurse, they always want an MD/DO-A and not a CRNA.

My concern is:

1) the cases that are not; even "healthy low risk" patients sometimes code on the table
2) if we don't ally ourselves with our anesthesia colleagues, in recognizing their superior fund of knowledge and skills, and support their cause then who will help us when someone decides that all breast biopsies are to be done by an RN, or trachs, or skin cancer excisions or…

Surgeons have been proven in the past to be too egocentric to think that anyone could tell them what to do, or to change their practice. So while I agree that a CRNA could do the vast majority of my cases and provide good care, I fear for the future of the specialty of anesthesia, family practice, and by extension, surgery.

Truth. Ask the CT surgeons who should be doing stents. It boggles my mind that there are CT surgeons out there "supervising" cardiologists during perc valves and, at my institute, vascular surgeons staffing the cardiology fellows on peripheral angios. Not exactly the same, but similar mistakes for sure.
 
And I'm not arguing that.

My cases are generally low risk ones performed in healthy patients. These are likely appropriately managed by a CRNA. The research they provide is weak with so many confounders as to be meaningless. The government, hospitals and lay public doesn't see that and therefore, think there is equivalence. Interesting however that when you operate on a nurse, they always want an MD/DO-A and not a CRNA.

My concern is:

1) the cases that are not; even "healthy low risk" patients sometimes code on the table
2) if we don't ally ourselves with our anesthesia colleagues, in recognizing their superior fund of knowledge and skills, and support their cause then who will help us when someone decides that all breast biopsies are to be done by an RN, or trachs, or skin cancer excisions or…

Surgeons have been proven in the past to be too egocentric to think that anyone could tell them what to do, or to change their practice. So while I agree that a CRNA could do the vast majority of my cases and provide good care, I fear for the future of the specialty of anesthesia, family practice, and by extension, surgery.

Isnt this just protectionism? You sort of made it sound in previous posts like your opinion was based on some concern for the safety of patients. But this seems more like naked protectionism. Its the MD equivalent of "they took our jeerrrrrrbs"
 
Isnt this just protectionism? You sort of made it sound in previous posts like your opinion was based on some concern for the safety of patients. But this seems more like naked protectionism. Its the MD equivalent of "they took our jeerrrrrrbs"
Its all of the above.

I believe that MD/DO-A provide better, safer care.

I believe that I should not be supervising someone doing a job that is not mine (nor mine to supervise).

And I believe in protecting what's mine. There's nothing wrong with protectionism especially if its based on the idea that fully trained physicians, surgeons and anesthesiologists alike, provide better care. Why do you believe its wrong?
 
Isnt this just protectionism? You sort of made it sound in previous posts like your opinion was based on some concern for the safety of patients. But this seems more like naked protectionism. Its the MD equivalent of "they took our jeerrrrrrbs"

Sounds like you don't think your MD anesthesia colleagues deserve a decent, respectable career, after going through years of training like you.
 
Its all of the above.

I believe that MD/DO-A provide better, safer care.

I believe that I should not be supervising someone doing a job that is not mine (nor mine to supervise).

And I believe in protecting what's mine. There's nothing wrong with protectionism especially if its based on the idea that fully trained physicians, surgeons and anesthesiologists alike, provide better care. Why do you believe its wrong?

There is a lot wrong with protectionism. Its a horrible economic policy, and is universally negative sum. It benefits those protected at the expense of everyone else, and in most cases it ends up not even benefitting those protected. It also is morally bankrupt by any moral philosophy I'm aware of.

If you truly believe they provide better care, then that should be your argument. But it isnt just that they need to provide better care, its that they need to provide more cost effective care. There are two sides to a cost:benefit ratio.

That has nothing to do with "we need to protect MD jerrrrbs." I think you are aware that that argument requires a little bit of evidence and that that evidence doesnt exist. Its possibly a correct argument, but its unclear who the burden should be on to prove it.
 
Sounds like you don't think your MD anesthesia colleagues deserve a decent, respectable career, after going through years of training like you.

I dont think they deserve some extra special protection to the detriment of others, no. I also dont think *I* deserve extra special protection. I stand on my own merits. It was mentioned earlier something like "how long until we have non-residency trained surg techs taking surgeon jobs?" Well, good. If I dont provide enough extra to be worth more than a surg tech, then I dont deserve my job.

Do you guys realize how bad this all sounds? Like, you realize that South Park episode was satire? "They are like me, therefore they deserve protection. Those others, from the outgroup, they arent like me, so **** those guys."
 
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All sorts of arguments get made. A minority maybe just want to protect these jobs for MDs, but the most valid arguments are related to patient safety. The burden of showing equivalence needs to be on those advocating for unsupervised anesthesia. The problem is that certain parts of the country are moving forward with CRNA only care without having met this burden. There are some remote rural areas that are probably justified in doing so because of the scarcity of resources but I see little reason for this to be seen in urban areas. Assigning supervision to the surgeon is just a bad idea. I've got enough on my plate when operating on a bleeding or toxic patient. Also, while anesthesia may appear on the SCORE curriculum I never sat on the other side of the drape during residency and therefore I am unequipped to serve in a supervisory role for even the most routine case.
 
I dont think they deserve some extra special protection to the detriment of others, no. I also dont think *I* deserve extra special protection. I stand on my own merits. It was mentioned earlier something like "how long until we have non-residency trained surg techs taking surgeon jobs?" Well, good. If I dont provide enough extra to be worth more than a surg tech, then I dont deserve my job.

Do you guys realize how bad this all sounds? Like, you realize that South Park episode was satire? "They are like me, therefore they deserve protection. Those others, from the outgroup, they arent like me, so **** those guys."

It doesn't matter what you think your merits are. What matters is what policy makers think of you. Do you really think that anesthesiologists don't offer "enough extra" vs. a CRNA and a family practitioner over a NP? Please don't tell me surgery is so complicated that a nurse can't do it. They probably can but will they do it well? Probably not. Wait until the day they are allowed to do the "simple" procedures and I want to know your reaction then.

Come on man. Your colleagues aren't in a good situation. I don't know why as a surgeon you're so against their predicament. It will certainly affect you in the future if your patients will end up in the care of CRNAs with no physician supervision.
 
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Sounds like you don't think your MD anesthesia colleagues deserve a decent, respectable career, after going through years of training like you.
and it is more than that, the minute you make something as important as the responsability for anesthesia outcomes as vague as they often are with unsupervised CRNA, you are hurting patient care. Most people dont realize but keeping the patient down, checking their status, having coordination with the surgeon and bring them back is 50% of the surgery. Having someone who can take full responsibility for that job and alone has all the meanings should something go wrong has the utter most importance.
 
Don't be so dramatic. 50% of the surgery is living through anesthesia? During residency and now two years in practice I've seen one MI at induction and never seen a pt die on the table. That's partly because I've worked with some terrific MD-As but also because modern anesthesia isn't like the old days of the ether cone where you were lucky to get out alive. Id say the perfect system is what I work with - crna with MD supervision. I'm comfortable with that and outcomes are good. I don't feel like I'm throwing my patients to the wolves in that set up.
 
Don't be so dramatic. 50% of the surgery is living through anesthesia? During residency and now two years in practice I've seen one MI at induction and never seen a pt die on the table. That's partly because I've worked with some terrific MD-As but also because modern anesthesia isn't like the old days of the ether cone where you were lucky to get out alive. Id say the perfect system is what I work with - crna with MD supervision. I'm comfortable with that and outcomes are good. I don't feel like I'm throwing my patients to the wolves in that set up.

Maybe true, for cookie-cut surgeries. Every thing is right until something goes wrong, though.
 
I'm not hating on the anesthesia guys at all.. I'm just making it clear that for a lot of patients it's just not that complicated. The anesthesiologist would tell you the same thing. It's just dishonest to make it seem magical that anyone makes it out alive. And most of what I do now is "cookie cut" but not at all the case during residency. I'm in favor of the MD-A supervision gig.
 
All the data everyone keeps asking about will come. As many have eluded to previously, all the current outcomes research attempts to look at anesthesitc realated morbidity and mortality which is rare and hard to tease out. But even in those situations evidence is present that supports decreased morbidity and mortality with anesthesiologist involvment. The classic study often pushed by my CRNA colleagues really should be thrown out but I want to dive into the article:

Outcomes looked at:
To measure possible anesthesia complications, we identified seven relevant patient safety indicators developed by the Agency for Healthcare Research and Quality:15 complications of anesthesia (patient safety indicator 1); death in low-mortality diagnoses (indicator 2); failure to rescue from a complication of an underlying illness or medical care (indicator 4); iatrogenic pneumothorax, or collapsed lung (indicator 6); postoperative physiologic and metabolic derangements, or physical or chemical imbalances in the body (indicator 10); postoperative respiratory failure (indicator 11); and transfusion reaction (indicator 16).

Numbers:
This left us with 481,440 hospitalizations for analysis, of which 412,696 were in non-opt-out states and 68,744 were in opt-out states. Of the latter, 41,868 hospitalizations occurred before the state had opted out. (so a total of 26,876 cases perfromed with a solo CRNA without a physician supervising.)

Hospitalizations without a Part B anesthesia claim were excluded unless a surgical procedure took place in a Medicare “pass-through” hospital. In these hospitals, claims for services by nurse anesthetists are rolled into (“passed through”) the Part A hospital claims. Therefore, observations from these hospitals were assigned to the certified registered nurse anesthetist solo category. (Most independent CRNAs cases occur in these hospitals, so of the 26, 876 total "solo CRNA" cases some of them likely did not even involve a CRNA...flex sigs, cardiac caths, lumps and bumps etc..and just had RN sedation)

Statistical games:
We did find that case-mix complexity was different for the two types of providers. Anesthesia base units for procedures in which anesthesiologists practiced solo were a full point higher than for procedures in which certified registered nurse anesthetists worked alone.
Although base units might not completely describe the complexity of either surgical or anesthetic procedures, base units were associated with a statistically greater mortality risk in our multivariate model. We estimate that each one-point increase in procedure base units is associated with a 7 percent higher mortality risk.

Anesthesiologists practicing alone were involved in more complex surgical procedures than certified registered nurse anesthetists practicing alone. Therefore, we adjusted anesthesiologist solo mortality rates by applying to the anesthesiologist solo group the nurse anesthetist case-mix for surgeries that the two providers had in common

So they looked at a very small number of basic surgical cases perfromed by "solo CRNAs" and found no difference in anesthetic related morbidity and mortality between solo CRNA and anesthesiologist involvement...real shocker. Not sure 26, 876 cases perfromed by "Solo CRNAs" over a 7 yr period even comes close to having enough power to suggest the following conclusion made by the article:

Policy Recommendations
Our analysis of seven years of Medicare inpatient anesthesia claims suggests that the change in CMS policy allowing states to opt out of the physician supervision requirement for certified registered nurse anesthetist reimbursement was not associated with increased risks to patients. In particular, the absolute increase in the provision of anesthesia by unsupervised nurse anesthetists in opt-out states was virtually identical to the increase in non-opt-out states, and the proportional increase was smaller in opt-out states.
This lends no support to the belief that a meaningful shift in provider shares occurred as a consequence of the policy change. Similarly, our analysis found no evidence to suggest that there is an increase in patient risk associated with anesthesia provided by unsupervised certified registered nurse anesthetists.
Both a change in the proportion of anesthesia provided by the different groups—nurse anesthetists alone, anesthesiologists alone, and nurse anesthetists and anesthesiologists working in teams—and a difference in the outcomes of the different groups are necessary to conclude that the change in CMS policy led to changes in patient safety. Because our data provide no evidence to support either of these conditions, we conclude that patient safety was not compromised by the opt-out policy.
We recommend that CMS return to its original intention of allowing nurse anesthetists to work independently of surgeon or anesthesiologist supervision without requiring state governments to formally petition for an exemption. This would free surgeons from the legal responsibility for anesthesia services provided by other professionals. It would also lead to more-cost-effective care as the solo practice of certified registered nurse anesthetists increases.
 
It's so much more than patient death .

There is no evidence for the majority of surgery cases that resident performed operations are inferior to ones performed by attendings. So why not just get rid of the supervision?

(Sarcasm)
 
Isnt this just protectionism? You sort of made it sound in previous posts like your opinion was based on some concern for the safety of patients. But this seems more like naked protectionism. Its the MD equivalent of "they took our jeerrrrrrbs"

Hospital executives must love you -- self-flagellating and not even out of training, rooting for a race to the bottom.
 
I dont think they deserve some extra special protection to the detriment of others, no. I also dont think *I* deserve extra special protection. I stand on my own merits. It was mentioned earlier something like "how long until we have non-residency trained surg techs taking surgeon jobs?" Well, good. If I dont provide enough extra to be worth more than a surg tech, then I dont deserve my job.

Do you guys realize how bad this all sounds? Like, you realize that South Park episode was satire? "They are like me, therefore they deserve protection. Those others, from the outgroup, they arent like me, so **** those guys."

A couple of issues. With no physician anesthesia supervision, who is stuck holding the bag regarding a patient outcome related to an anesthesia complication? I do not have the skill nor desire to manage/supervise a CRNA during a hysterectomy, C-Section, or even D+C. And while anesthesia may be incredibly safe and effective, the complication rate is not zero. What I have seen now is hospital administrators are more than willing to essentially play Russian roulette with lowering costs and if a bad outcome occurs, the hospital will eat the judgement out of their war chest. Why should admins/execs care? They won't get named in a lawsuit or have issues with their medical license or have any inkling of guilt.

I'm at a mid size community hospital in the middle of nowhere with 500 beds. The hospital is literally a billion dollar enterprise with millions in yearly revenue. Even though it is technically non profit, the level cost cutting is ridiculous even in the most minute things. And hospital execs are continually pushing the limit with how much they can get away with regarding costs/supervision etc. There are a ridiculous number of hospitals out there like this generating huge amounts of money under the guise of being not for profit while the CEO and VPs (usually there's at least 30 or 40 of them) collect ridiculous 7 figure incomes and absurd retirement packages.

This also relates to what is a non physician allowed to do. CRNAs do well because they are essentially trained by anesthesiologists. They basically have a mini residency and have time to expand there skills on low risk patients with constant supervision. I can easily see this transferred to surgical fields. Why couldn't a non physician perform an appy on a virgin belly or a primary C/D? Have them do on the job training and I bet their outcomes for certain procedures would be very similar. But then this begs the question, if you want the pay/responsibility/breadth of skill, why don't you go to medical school. Quit trying to backdoor these things. It's irritating as hell, especially when bogus studies comes out that push a specific agenda on patient outcomes.

The hospital execs wet dream is an army of midlevel providers in all fields being payed maybe half of what they would pay a physician, with just a handful of supervising docs to clean up any messes . Of course when it comes to their care and that of their family, we know what they would want/demand.

The game is rigged. Do not undersell your skill/training or that of your colleagues or the different specialties in medicine are going to get hammered jointly.
 
I refuse to operate at facilities that are only staffed by CRNAs. I live in a large city where these decisions are made not because of a shortage of excellent anesthesiologists but rather as a cost saving measure at the expense of the patient. These hospitals are also unable to show the surgeons any proof that we are not the supervising physician during the case should some **** go down. Our physician colleagues deserve our support against this war on their livelihood as do our patients.

Daaaaaaaaamn Kim! Thanks a lot for that. I really appreciate the sentiment.
 
A couple of issues. With no physician anesthesia supervision, who is stuck holding the bag regarding a patient outcome related to an anesthesia complication? I do not have the skill nor desire to manage/supervise a CRNA during a hysterectomy, C-Section, or even D+C. And while anesthesia may be incredibly safe and effective, the complication rate is not zero. What I have seen now is hospital administrators are more than willing to essentially play Russian roulette with lowering costs and if a bad outcome occurs, the hospital will eat the judgement out of their war chest. Why should admins/execs care? They won't get named in a lawsuit or have issues with their medical license or have any inkling of guilt.
...
The hospital execs wet dream is an army of midlevel providers in all fields being payed maybe half of what they would pay a physician, with just a handful of supervising docs to clean up any messes . Of course when it comes to their care and that of their family, we know what they would want/demand.

The game is rigged. Do not undersell your skill/training or that of your colleagues or the different specialties in medicine are going to get hammered jointly.

Its considered the cost of doing business: spend less paying your anesthesia providers (although not much less as CRNAs demand more) and more paying out malpractice.
 
Isnt this just protectionism? You sort of made it sound in previous posts like your opinion was based on some concern for the safety of patients. But this seems more like naked protectionism. Its the MD equivalent of "they took our jeerrrrrrbs"

Seriously dude? Everywhere I've been that uses CRNA's, I've had an experience where they freak out over something and the attending has to come in and reassure them.

Just had a case the other day where the patient started going brady while we insufflated, and the CRNA was losing her mind. She was calling for drips, bloods, etc and wanted to stop the case immediately. Thankfully, her attending came in and calmed her down. She was not a new CRNA either. All we had to do was desufflate, tell her to give some volume, and everything was fine.

And the liability is a huuuuuge concern, in my opinion. I don't want to be the responsible physician for anesthesia. I don't know about you guys, but my program doesn't really focus on anesthesia training.
 
I dont think they deserve some extra special protection to the detriment of others, no. I also dont think *I* deserve extra special protection. I stand on my own merits. It was mentioned earlier something like "how long until we have non-residency trained surg techs taking surgeon jobs?" Well, good. If I dont provide enough extra to be worth more than a surg tech, then I dont deserve my job.

Do you guys realize how bad this all sounds? Like, you realize that South Park episode was satire? "They are like me, therefore they deserve protection. Those others, from the outgroup, they arent like me, so **** those guys."

First they came for the Socialists, and I did not speak out—
Because I was not a Socialist.

Then they came for the Trade Unionists, and I did not speak out—
Because I was not a Trade Unionist.

Then they came for the Jews, and I did not speak out—
Because I was not a Jew.

Then they came for me—and there was no one left to speak for me.
 
Seriously dude? Everywhere I've been that uses CRNA's, I've had an experience where they freak out over something and the attending has to come in and reassure them.

Just had a case the other day where the patient started going brady while we insufflated, and the CRNA was losing her mind. She was calling for drips, bloods, etc and wanted to stop the case immediately. Thankfully, her attending came in and calmed her down. She was not a new CRNA either. All we had to do was desufflate, tell her to give some volume, and everything was fine.

And the liability is a huuuuuge concern, in my opinion. I don't want to be the responsible physician for anesthesia. I don't know about you guys, but my program doesn't really focus on anesthesia training.

The fact is the level of training for an MD is just greater than that for a CRNA. A simple analogy is a car repair man. If all you need is a tire and oil change, then anyone can do it. But for a really complex job, you need an experienced expert. So why not just say since most patients are healthy anyone can give anesthesia, CRNA included? Because even healthy patients can become unhealthy very quickly under anesthesia and during surgery. So a better (and I know tired) analogy is a pilot. Do you want your pilot of a 747 to be someone with basic flight training or some one with more years of training, problem-solving, and experience?
 
I would say that a new grad MD-A and a new grad CRNA, there's no doubt in the world who you'd want. But your analogy fails to understand that CRNAs give anesthesia all the time, multiple cases a day. Over the years, that gap closes. I'm not negating the need for MD-As. I strongly advocate for a CRNA and MD-A supervision model. But a seasoned CRNA is more than capable of giving a very good anesthetic. The humor/irony in all this is that MD-As wanted CRNAs so they could make more money. Oversee here and there and rake in the cash. But that greed has now come along to bite them in the butt.
 
I would say that a new grad MD-A and a new grad CRNA, there's no doubt in the world who you'd want. But your analogy fails to understand that CRNAs give anesthesia all the time, multiple cases a day. Over the years, that gap closes. I'm not negating the need for MD-As. I strongly advocate for a CRNA and MD-A supervision model. But a seasoned CRNA is more than capable of giving a very good anesthetic. The humor/irony in all this is that MD-As wanted CRNAs so they could make more money. Oversee here and there and rake in the cash. But that greed has now come along to bite them in the butt.
 
Anyone who feels that way never saw difference between the way a doctor vs a CRNA takes care of a critically ill patient from beginning to end (preop, intraop, postop). It doesn't matter how many years you've worked on a Ford. A Ford mechanic still can't take repair a broken Bentley. And a pilot flying a Cessna for 20 years still can't land a 747 in an ice-storm. This is speaking as someone who is doubly-boarded, spend several years in the ICU, and trained both residents and CRNAs. True, most well-trained CRNAs can handle simple cases. But when the %&$# hits the fan, the majority of CNRAs still call their supervising anesthesiology physicians, and the majority of surgeons, even those OK with a CRNA taking care of healthy patients, still ask for the MD, stat. That's still the way it is in 2015. But the Affordable Care Act is trying to change that. And do you think the primary reason for the change is to improve quality of care? Despite any claims otherwise, it is to save money. By the way, since you mentioned it, why do CRNAs want more independence? To improve patient care? No, it's to make more money. Nothing wrong with trying to make money. It's just that when you claim as a CRNA it's equal care, it means you don't understand the nature of critically illness and you're being disingenuous. Pity the poor public. They are the ones who don't understand. They can't tell the difference between a CRNA who took an online course and introduces him/herself as doctor (we both know that's happening) and a real physician. Until the patient develops a complication. Yes, it may be hard to prove in the literature. But even the efficacy of the pulse ox and capnogram have not been PROVEN to save lives in the literature. Let me end by asking you a question. If you were undergoing an operation and unexpectedly developed a life-threatening intraoperative complication, whom would you want to take care of you, the average CRNA with 20 years experience average Board-certified MD anesthesiologist with 20-years of experience? I know my answer...
 
Your points are well taken, which is why I made the point that I advocate a CRNA and supervision model. 95% or more of what comes to an OR can be safely managed by a seasoned CRNA. The other 5% needs some oversight and supervision, which is the current model I see used. Anyway I'm certain it bothers you that there are proposed changes to your profession. I get that, but anyone could have seen this coming years ago when the model of care started. It's a great lesson for the rest of us as mid-levels infringe on our professions.
 
Your points are well taken, which is why I made the point that I advocate a CRNA and supervision model. 95% or more of what comes to an OR can be safely managed by a seasoned CRNA. The other 5% needs some oversight and supervision, which is the current model I see used. Anyway I'm certain it bothers you that there are proposed changes to your profession. I get that, but anyone could have seen this coming years ago when the model of care started. It's a great lesson for the rest of us as mid-levels infringe on our professions.

The problem with what you suggest is that anesthesia is like flying a plain. Everything is fine until it's not. Having been through my share of critical events, it's the simplest cases that develop anaphylaxis, MH, spontaneous tension pneumothorax, bronchospasm, high spinal, protamine reaction, venous air or CO2 embolism, laryngospasm, unexpected difficult airway, aspiration, hyperkemic arrest, amniotic fluid embolus, tension pneumothorax, vasoplegia from ACEI. And you never know when it's going to happen. (Just like flying a plane.) So if you are indeed in support of an anesthesiology MD supervisory model, I would agree. But what CRNAs are trying to do is to opt out from the need for any anesthesiology MD supervision whatsoever. In my opinion, it is a dangerous trend of events. [Let's assume, as you say, only 5% of all surgical cases needed oversight and supervision. Let's say there are 50 million outpatient procedures performed in the US per year. Let's also say CRNAs could handle 80% of those serious events by themselves (and I feel I'm really being generous with that number). Under the proposed CRNA model in which there would no MD anesthesiologist to supervise these events, that would be 50 million x 5% x 20% = 500,000 patients who could suffer due to lack of MD availability. We can quibble over the numbers and assumptions of the calculation, but are you really ready to accept that such a potential complication rate? The Obama administration is.
 
Just had a case the other day where the patient started going brady while we insufflated, and the CRNA was losing her mind. She was calling for drips, bloods, etc and wanted to stop the case immediately. Thankfully, her attending came in and calmed her down. She was not a new CRNA either. All we had to do was desufflate, tell her to give some volume, and everything was fine.

The opposite happens too when an experienced CRNA thinks they have handle on things and don't quite realize what is going on. I have had to say a few times- "Get your staff in here now." I just don't think mid-level providers in any field will grasp the pathophysiology needed to manage what I refer to as "the margin"- those 5% or so of situations that are not normal. Unfortunately for those pushing mid level providers as the solution, a seemingly normal case can frequently be a 5%-er dressed up real pretty, then boom, real trouble.
 
The opposite happens too when an experienced CRNA thinks they have handle on things and don't quite realize what is going on. I have had to say a few times- "Get your staff in here now." I just don't think mid-level providers in any field will grasp the pathophysiology needed to manage what I refer to as "the margin"- those 5% or so of situations that are not normal. Unfortunately for those pushing mid level providers as the solution, a seemingly normal case can frequently be a 5%-er dressed up real pretty, then boom, real trouble.

I totally agree. It's all part of the mentality that CRNAs believe MDs are not necessary. I can't tell you the number of times a critical event occurred, the CRNA didn't call or called too late, and bad things happened. In fact, in reference to what Pir8DeacDoc said about the quality gap between CRNAs and MDs closing with years of experience, it is often the more experienced CRNAs that are least likely to call for help. Whereas for me, the opposite is true. I've been in private practice for over 20 years and I have learned to call for help more than ever. Just to get ready, mobilize resources, have equipment or drugs available. Better safe than sorry is my attitude. Maybe it's a function of the genial nature of the particular group I'm with, but no one seems to mind. We all understand we're in it together and patient care comes first. This is not the idea embraced by the CRNA campaign for independence.
 
Isnt this just protectionism? You sort of made it sound in previous posts like your opinion was based on some concern for the safety of patients. But this seems more like naked protectionism. Its the MD equivalent of "they took our jeerrrrrrbs"

Just notice the above comments. In fact, it is the CRNAs are the ones practicing boldfaced protectionism. By lobbying at a national and state level to deny anesthesia assistants (AAs) the right to practice, they are restricting the trade of legitimate competion and furthering their goal of replacing physicians. Again, the public doesn't see this, and again, will be made to suffer. Only when it is too late, when the MDs have been squeezed out of the market and the quality of care reduced to socialist levels of mediocrity, will we realize what has happened.
 
Vis-a-vis CRNAs, I can say that the midlevel situation in inpatient medicine is - from my perspective - somewhat of a disaster for medicine as a whole. Outpatient subspecialized clinics I think they can handle OK. But in just 6 months of intern year I have seen quite a few cases where the midlevels either don't know what they're doing (because they're not being supervised) or they are very quick to get pushy with the MDs earlier in training but then immediately cry for upper level MD assistance when things don't go as planned.

The neonatal NPs who glare at the interns and don't let them learn emergent intubation on premies will immediately call out for the fellow to save the day when they themselves cannot intubate the baby.

The surgical PAs and NPs running the floors who do not restart ASA post-op on a patient with a CVA history, who fluid restricted a dehydrated orthostatic syncopal man who was hyponatremic and hypovolemic due to inadequate PO intake (I guess they thought he had SIADH?!?!), who did not restart anticoagulation until 6 days post-op in a woman who is lupus anticoagulant positive and had a PE 3 years back and is now starting to get dyspneic and needs supplemental O2...

And I have seen a number of elderly patients who underwent a major permanent deterioration in mentation and cognition after surgery. I'm not talking brief post-op delirium. Whether it was the surgical procedure itself (very doubtful) or events that transpired under the cover of anesthesia such as a cerebral hypoperfusion event (my bet is on this) is unclear, but I expect that anesthesiology will need to start looking some weeks to months post-op to assess differences in morbidity in CRNA- vs. MD-provided anesthesia.
 
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