CRNAs and pain management in Alabama

[ProRealDoc]

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I say they need to be stopped.

http://blog.al.com/sweethome/2010/11/ftc_urges_alabama_medical_pane.html

WASHINGTON -- A proposal by Alabama's Board of Medical Examiners would make pain management services more expensive and harder to find, according to the Federal Trade Commission, which is asking the state board to reject the rule.

The Board of Medical Examiners in July, citing patient safety concerns, recommended that certain treatments for pain be performed solely by doctors and not be delegated to others.

But the FTC said there is no evidence that allowing certified registered nurse anesthetists to do the work has harmed patients, and barring them from it could make things worse for people suffering from chronic pain.

"Unnecessary restrictions on the ability of physicians to provide pain management services in collaboration with the CRNAs are likely to reduce the availability, and raise the prices, of pain management services in Alabama," the FTC stated in it's letter to the board Nov. 3.

The agency said the limits on the nurse anesthetists would negatively affect cancer patients and others with chronic pain, people in rural areas, lower-income patients and hospice patients. Some of the pain management treatments that CRNAs would no longer be allowed to administer include steroid injections, epidural injections and nerve blocks, but the proposed rule names dozens of specific procedures.

The Alabama Association of Nurse Anesthetists called the proposed rule "an outrageous and radical assault" on CRNAs and urged its members to file written comments in opposition.

"We are just two professions with very similar or the same subset of skills and with the (new federal) health care plan that's going to be in place, there's room for all of us," said Jennifer Overton, a CRNA in Birmingham. "CRNAs, most of them are in rural areas and anesthesiologists don't want to work there. It's a disservice to the citizens of this state for them to have to drive for hours, when they're in chronic pain already."

The Alabama Board of Nursing has ruled the interventional pain management techniques are within the scope of CRNA practice in Alabama.

"If the Board of Medical Examiners can usurp the power of the Board of Nursing, what's next?" Overton said.

The Alabama Board of Medical Examiners is scheduled to discuss the issue at its meeting Wednesday in Montgomery.

The doctors say Alabama is just the latest of several states to respond to the American Medical Association's raising the standard of care for certain types of interventional pain management. The proposal is not intended to marginalize CRNAs, but to improve patient safety, they say.

"Interventional pain management by unqualified providers presents serious risks to patients such as persistent or worsened pain, bleeding, infections, nerve damage, brain damage, paralysis or even death," the proposed rule states.

"We weren't trying to restrain trade or put anybody out of work," said Larry Dixon, executive director of the Alabama Board of Medical Examiners.

He said the public's comments, written and delivered during a three-hour public hearing, have been compiled and delivered to board members, who will decide whether to proceed with the proposed rule, change it or scrap it altogether.

Dixon, who has worked for the state board for 30 years, also said it was the first time the Federal Trade Commission had weighed in on a proposed rule affecting doctors in Alabama.

"Am I looking for a fight with Uncle Sam? No," Dixon said. He believed the board would discuss the matter but probably not make a final decision Wednesday.

The Federal Trade Commission, in its letter to the Alabama board, said it recently urged several states "to reject or narrow restrictions that limit health care access and raise prices to consumers by limiting competition among health care providers and professionals."

 

[JLM]

http://blog.al.com/spotnews/2010/11/alabamas_nurse_anesthetists_ca.html



A state medical board today indefinitely delayed a proposal that would have allowed only doctors to perform certain pain treatments.

The proposal was controversial because it would have made certified registered nurse anesthetists stop performing the treatments. The Federal Trade Commission had asked that the rule be rejected, saying it would make pain management services more expensive and harder to find, particularly in rural areas with limited health care resources.

The Alabama Board of Medical Examiners said today it needs more time to read all of the public comments on the proposal and will wait for two national organizations to finish studies they are conducting on the pain treatments.

"These organizations have the resources to do the studies and gather the data on, one, is harm being done; two, what kind of harm is it; and three, what is best for patient care," said board Executive Director Larry Dixon.

The treatments that would have been affected included epidurals and nerve blocks.






The mother-f*cking FTC?

Did the state medical board really bow down to CRNAs and hand them interventional pain on a platter?

Ugh, for the first time I am really questioning my specialty choice.

 

[OB1🤙]

What's lost in all this is that non-fellowship trained MDs don't do these procedures, BECAUSE THEY KNOW THEY AREN'T QUALIFIED TO DO THEM, even after a four-year residency. Yeah, I did a bunch of procedures during my chronic pain rotation. Yeah, if you handed me a touhy and a vial of steroids I could guide them into them into the epidural space. But the procedural monkey-skill part of pain practice isn't the hard part, and they don't get that.

I think Wesley Snipes said it best when he said, "You can put a cat in the oven, but that don't make it a biscuit."

 

[Coastie]

The arrogance and ignorance of these nurses never ceases to amaze me.

 

[IlDestriero]

What's lost in all this is that non-fellowship trained MDs don't do these procedures, BECAUSE THEY KNOW THEY AREN'T QUALIFIED TO DO THEM, even after a four-year residency. Yeah, I did a bunch of procedures during my chronic pain rotation. Yeah, if you handed me a touhy and a vial of steroids I could guide them into them into the epidural space. But the procedural monkey-skill part of pain practice isn't the hard part, and they don't get that.

I think Wesley Snipes said it best when he said, "You can put a cat in the oven, but that don't make it a biscuit."

You're absolutely right. I almost went into pain and did several extra months in the procedure heavy pain clinic. We got referrals all the time for requests for ESIs, blocks, etc. Many times it was not appropriate, often something else was needed, etc. We weren't getting referrals from dopes, I'm sure it's that way everywhere. Doing that exam and DDx IS the practice of medicine. We reviewed studies ourselves, took a detailed hx, generated a DDx and a treatment plan. These pathetic CRNAs, who will bill as much as the fellowship trained MD, will just needle jockey the procedure requested and send them back to the PCP for opiates. Bad medicine, bad practice, inappropriate and unnecessary procedures, inappropriate med management, etc. That's what they're offering.
The more I see this stool spreading, the more I really want to leave in 5-10 years, and take the best we have to offer with me abroad.

 

[leaverus]

What's lost in all this is that non-fellowship trained MDs don't do these procedures, BECAUSE THEY KNOW THEY AREN'T QUALIFIED TO DO THEM, even after a four-year residency.

EXCELLENT point. I'm simply not qualified to manage chronic pain and the idea of doing so scares me - i'll be the first to admit that; it's not an easy thing trying to treat someone with chronic pain - they are often some of the most complex individuals to deal with. Why are CRNAs are so blinded by ambition and greed that they're so willing to place others at risk?

 

[pd4emergence]

I love how CRNA's always make the cost argument. They neglect to say that they are reimbursed pretty much the same. I love how they make access to care an arguement when people here in Alabama routinely drive to an hour because they want high quality health care. Multiple states have fought this same fight and rules like this have been upheld by state courts. I believe this will go forward in Alabama. We will end up in court. The only difference here is that the FTC has now gotten involved and now the Board has to figure out how to deal with that challenge. F'in feds. Since when does the FTC get to dictate health care policy in a state. I have to say most CRNA's in alabama are not interested in doing pain blocks. Most also are not interested in providing anesthesia solo. Not many CRNA's here are doing pain inverventions. From a business standpoint there is just not that much competition. This has been a quality and safety issue from the beginning. I wonder if the FTC is gonna start sticking it's nose in all of the scope of practice fights that are going on. Nurses prescribing everything, optometrists doing eye surgery, psychologists prescribing without training, CRNA's and the OR, the list goes on. Pretty soon associate degrees are gonna get you prescribing rights. If you are a CRNA and have an associate degree grandfathered in it seems like your chance is coming. This is a dangerous precedent. I hope there is a concerted effort by the ASA to keep the FTC from being able to set it. If so we are screwed. Give to the PAC.

 

[jwk]

What's lost in all this is that non-fellowship trained MDs don't do these procedures, BECAUSE THEY KNOW THEY AREN'T QUALIFIED TO DO THEM, even after a four-year residency. Yeah, I did a bunch of procedures during my chronic pain rotation. Yeah, if you handed me a touhy and a vial of steroids I could guide them into them into the epidural space. But the procedural monkey-skill part of pain practice isn't the hard part, and they don't get that.

I think Wesley Snipes said it best when he said, "You can put a cat in the oven, but that don't make it a biscuit."

Where did you get that idea? I think that's part of the problem. Non-fellowship trained MD's do indeed do these procedures. A lot of non-anesthesiologists do these procedures. Any physician can rent an office and a C-arm and write lots of prescriptions and call himself a pain medicine specialist. It's not right, it's not smart, but it's not uncommon either.

 

[izpibhdglyoatu]

Where did you get that idea? I think that's part of the problem. Non-fellowship trained MD's do indeed do these procedures. A lot of non-anesthesiologists do these procedures. Any physician can rent an office and a C-arm and write lots of prescriptions and call himself a pain medicine specialist. It's not right, it's not smart, but it's not uncommon either.

When they get sued for malpractice, they will have no way to defend themselves.

 

[GasEmDee]

Where did you get that idea? I think that's part of the problem. Non-fellowship trained MD's do indeed do these procedures. A lot of non-anesthesiologists do these procedures. Any physician can rent an office and a C-arm and write lots of prescriptions and call himself a pain medicine specialist. It's not right, it's not smart, but it's not uncommon either.

I am vehemently against this practice as well.

 

[leaverus]

Where did you get that idea? I think that's part of the problem. Non-fellowship trained MD's do indeed do these procedures. A lot of non-anesthesiologists do these procedures. Any physician can rent an office and a C-arm and write lots of prescriptions and call himself a pain medicine specialist. It's not right, it's not smart, but it's not uncommon either.

Where did you get the idea that they do?? I'm not saying there aren't ANY who do, because i personally know at least one non-fellowship trained guy who treats pain patients, but the main point is that the VAST MAJORITY of anesthesiologists don't, because know they are not qualified to and do not care to manage chronic pain. So, among anesthesiologists it is uncommon.

 

[Taurus]

Let the feds take it to court. Let the courts rule that interventional pain is a practice of medicine like they did in Louisiana.

 

[geauxg8rs]

I like how the crna mentioned lives in Birmingham. Hardly a rural area or an underserved area for interventional (or non interventional) pain. Are we to assume Miss Overton is going to
move to the sticks?

 

[Southpaw]

There is nothing in a CRNAs training that qualifies them for chronic pain management. Absolutely nothing. Nothing they do in their glorious, coveted ICU time exposes them to chronic pain management. Nothing they do in their nurse anesthesia schooling exposes them to the field (outside of a few schools that send them to the pain clinic for a week or so, or a month maximum).

They are completely unqualified to practice in this field, as putting needles in a patient's back is not and should not be mistaken for qualification to practice chronic/interventional pain management. They need to fess up to this fact and quit crying about how the big, bully doctors won't let the nurses play doctor anymore.

And to the CRNAs who want 'fellowship' training by way of their DNAP, this is precisely the point that they need to look themselves in the mirror and repeat "I just should've gone to medical school.....". The Alabama Medical Board needs to grow a pair and lay the smack down. The government has no business meddling in their business, and they need to be treated as such. CRNA does not an Anesthesiologist make, and when we start to discuss fields like chronic pain medicine, which requires fellowship-training, it becomes crystal clear that nurses are just trying to play doctor here, and patients are getting short-changed.

Does the field of chronic pain management need to completely restrict itself to ONLY fellowship-trained physicians? Yes, no doubt it. Does the fact that non-fellowship trained physicians currently practicing in the field mean that any Joe Schmoe CRNA, RN, BS, EMT, H.S. Diplomate, Grade School graduate, Apple of Mommies Eye, OMFGSTOPWITHTHEINFERIORITYCOMPLEX should be allowed to practice medicine, but call it nursing, also? Hell no. I repeat...Hell no. Alabama, man up. Put the smack down....you're long overdue.

 

[Taurus]

I heard the Alabama medical board tabled the proposal for now pending some national studies on the issue.

Unless CRNA's suddenly have gained more training and experience doing interventional pain medicine since the Louisiana case, the studies will probably show that CRNA's are unqualified. That's the cover that medical boards across the country need to pass similar proposals.

 

[leaverus]

When CRNAs begin to claim that INTERVENTIONAL PAIN is within their scope of practice, it becomes obvious that absolutely EVERYTHING they do is motivated by greed and ambition and never by concern for patients.

 

[OB1🤙]

My exposure to this field has always been with fellowship-trained physicians, hence the slant of my post above.

I absolutely, positively do not think that anyone but a fellowship-trained physician should be practicing this field, unless they began practice before pain fellowships were available.

If some shady docs are out there running pill mills and epiduralizing anybody that walks through the front door with a valid insurance card, I think that's every bit as abhorrent as a CRNA trying to practice interventional pain medicine.

Once again, this has nothing to do with procedures. A fellowship is an apprenticeship in the decision-making process that goes into managing these patients. The procedural aspect is nowhere near as important as the diagnostic decision-making and therapeutic decision trees that one learns over the course of a year spent immersed in an experienced physician's pain practice.

There's a reason this apprenticeship is a year long, not a weekend. This is not no-brainer medicine. The fact that I'm good at dosing dilaudid at the end of a surgical case and know my way around an epidural tray doesn't have any bearing on my ability to decide whether a patient would benefit from a diagnostic medial branch block, or if another should have a spinal cord stim vs. intrathecal pump vs. a reassuring pat on the shoulder and uptitration of opana.

So my point then is this: familiarity with narcotics and neuraxial blocks does not make someone ready to practice interventional pain. They might provide a reasonable basic foundation, but without an intensive apprenticeship as obtained in a certified fellowship, you're a quack, whatever the letters after your name are.

Edit: And since I see my first post managed to get quoted "over there," let me respond to MmacFN directly and say that you're dead wrong: this doesn't have a damn thing to do with money. It IS about patient safety. I'm sorry if that doesn't fit your narrative that we're a bunch of greedy scumbags, but it's true.

 

[dhb]

I absolutely, positively do not think that anyone but a fellowship-trained physician should be practicing this field, unless they began practice before pain fellowships were available.

I totally agree, this has nothing to do with the letters behind the name but with proper training which is much broader than giving a shot in the back and a prescription.
Of course the wannabe doc can't understand that how could they?

 

[rubenk1]

I love how this guy updated his comment regarding CRNA salaries but refuses to admit he may have wrote a "slightly" misguided article regarding the Alabama CRNA pain situation:

http://www.slate.com/id/2274428/