Don't Go into Anesthesiology

[BLADEMDA]

No Harm Found When Nurse Anesthetists Work Without Supervision By Physicians
No Harm Found When Nurse Anesthetists Work Without Supervision By Physicians

Health Affairs, 29, no. 8 (2010): 1469-1475
doi: 10.1377/hlthaff.2008.0966
© 2010 by Project HOPE



U.S. Health Care Workforce

No Harm Found When Nurse Anesthetists Work Without Supervision By Physicians

Brian Dulisse1 and Jerry Cromwell2,*

1 Brian Dulisse is a health economist at the Research Triangle Institute, in Waltham, Massachusetts.
2 Jerry Cromwell ([email protected]) is a senior fellow in health economics at the Research Triangle Institute.

In 2001 the Centers for Medicare and Medicaid Services (CMS) allowed states to opt out of the requirement for reimbursement that a surgeon or anesthesiologist oversee the provision of anesthesia by certified registered nurse anesthetists. By 2005, fourteen states had exercised this option. An analysis of Medicare data for 1999–2005 finds no evidence that opting out of the oversight requirement resulted in increased inpatient deaths or complications. Based on our findings, we recommend that CMS allow certified registered nurse anesthetists in every state to work without the supervision of a surgeon or anesthesiologist.

Key Words: Health Economics • Legal/Regulatory Issues • Medicare

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[BLADEMDA]

We are at war with the Anesthesia Nurses/AANA and we are losing.
It is quite possible or even highly likely that the Federal Govt. via CMS (Medicare/Medicaid) will realize that Anesthesiology/Anesthesia is a field of Nursing and NOT a field of Medicine.

The leadership has sold out the profession and continues to train M.D./DO replacements every day right alongside you at your Residency Programs.
The ASA and University Chairs have about 5 years left to act swiftly and make corrective actions.

I must strongly caution Medical Students about the pitfalls of this field and advise the stronger applicants to Match elsewhere.

After graduating Medical School you deserve more than becoming a Glorified Anesthesia Nurse.

 

[BLADEMDA]

For those of you who are "stuck" in this field for one reason or another here is my advice:

1. Work as hard as possible to earn money while the field is still viewed as a Medical Specialty

2. Think about completing a fellowship because the Nurses don't have them (yet).

3. Develop a back-up plan if the field becomes "Nursing" circa 2020

4. Get comfortable with the concept of becoming a fireman as that will likely be your job in the operating room suite in ten years.

 

[jwk]

BTW, this "study" was bought and paid for by the AANA.

 

[lakersbaby]

BTW, this "study" was bought and paid for by the AANA.

i think thats the main point though all of these studies that everyone keeps posting are paid for by the AANA, but the more of these "studies" that come out without any protest the more they will be perceived as valid.

 

[BLADEMDA]

i think thats the main point though all of these studies that everyone keeps posting are paid for by the AANA, but the more of these "studies" that come out without any protest the more they will be perceived as valid.

Exactly. The AANA continues to fund their propaganda war through the realm of "studies." In the real world Solo CRNA practice is fraught with disaster which is why many of us will have jobs as a Fireman no matter what the AANA gets published.

 

[BLADEMDA]

 

[IlDestriero]

The nursing school and medical school are separate. If a hospital refused to train it's university CRNAs there would likely be a mandate from Dean to Dean to train them. Even if they stopped, they would just go across town. Even if the university programs closed CRNA schools, they would just go to a CRNA mill. There is no stopping them. The answer lies within your state, and if that fails, your hospital. When that fails, the real data will be available eventually, though they're not going to be studying it. We will look back on these days as the golden age of medicine, from our ocean view condo in Sydney.
Anyone committed to anesthesia not doing a fellowship is taking a big gamble, and even that may not be enough eventually.

 

[BLADEMDA]

The nursing school and medical school are separate. If a hospital refused to train it's university CRNAs there would likely be a mandate from Dean to Dean to train them. Even if they stopped, they would just go across town. Even if the university programs closed CRNA schools, they would just go to a CRNA mill. There is no stopping them. The answer lies within your state, and if that fails, your hospital. When that fails, the real data will be available eventually, though they're not going to be studying it. We will look back on these days as the golden age of medicine, from our ocean view condo in Sydney.
Anyone committed to anesthesia not doing a fellowship is taking a big gamble, and even that may not be enough eventually.

Why can't the CRNA train the SRNA? After all, they are equal to an Attending. Just ask them or the Nurses at Fantasyland.org

 

[Mac4]

While I certainly understand you are concerned about the future of our specialty, it is really not cool to put a thread like this in a public forum, especially right before residency applying/interviewing season. It is scaring poeple away.

We need good and bright people to join us, promote our specialty and "fight" AANA.

 

[jwk]

The nursing school and medical school are separate. If a hospital refused to train it's university CRNAs there would likely be a mandate from Dean to Dean to train them.

The key is the department chairman. HE/SHE controls what goes on in the anesthesia department. I know of at least one chairman who will not allow CRNA students in his hospitals to do any regional anesthesia of any kind so as not to take away from the residents opportunities to do so, and has told the dean of the nursing school that they can get their regional experience elsewhere. Great guy.

 

[IlDestriero]

While I certainly understand you are concerned about the future of our specialty, it is really not cool to put a thread like this in a public forum, especially right before residency applying/interviewing season. It is scaring poeple away.

We need good and bright people to join us, promote our specialty and "fight" AANA.

At least the readers will know what they are getting into over their career. I'm not so worried about the next 5-10 years, but beyond that, who knows. Other specialties are more secure for those with an interest in them. I also won't lose sleep working for 225k if it comes to that. If you are coming in looking for >400, you're going to probably be disappointed. Of course all physician salaries will almost certainly decline. I expect no raises to counter cost of living increases, and significant reimbursement decline as well, toward Medicaid levels, which might actually rise.

 

[BLADEMDA]

While I certainly understand you are concerned about the future of our specialty, it is really not cool to put a thread like this in a public forum, especially right before residency applying/interviewing season. It is scaring poeple away.

We need good and bright people to join us, promote our specialty and "fight" AANA.

Sorry to burst any bubble. My thread was in reference to those top applicants who want a field with more earning potential. The midlevel threat is not only real it is likely a political reality in about 10 years.

Plus, you wil have to put up with a whole new breed of militant Doctor of Nurse Anesthesia providers who will view themselves as your equal.
How long until those DNAPs are teaching Residents? This field isn't just under an attack it is under seige.

 

[BLADEMDA]

Here is my worst case scenario circa 2020. The DNAP CRNA is doing his/her own cases without supervision. The MD (A) does critical/high acuity cases and helps put out fires in the O.R. Most hospitals cut back on MD providers and utilize the CRNA. MDs cover call or back-up call and do cases along with CRNAS.

CMS declares this field Nursing and slashes reimbursement by 50% from today's already low level. CRNAs take a 40% pay cut and we get the same. Most MDs are employed by the hospital or are co-owners in a surgi-center. Private Insurance(whatever remains) also cuts reimbursement for this nursing field by 50%.

So, this field is viewed by the govt and Insurance companies as a Nursing level duty. Regardless of what your University Attendings think or say the reality is a CRNA can legally perform all the same duties as an Anesthesiologist(except TEE, Bronchoscopy and Pain Management) at half the cost.

Thus, as long as you don't mind end up being a Fireman and/or Glorified Anesthesia Nurse (with a Doctorate) then this field is for you.

 

[proman]

Regardless of what your University Attendings think or say the reality is a CRNA can legally perform all the same duties as an Anesthesiologist(except TEE, Bronchoscopy and Pain Management) at half the cost.

There is a movement from the AANA pushing the ASE to change this. It appears that the cardiologists are going with it.

 

[BLADEMDA]

There is a movement from the AANA pushing the ASE to change this. It appears that the cardiologists are going with it.

I love it. So new Residents need a 12 month fellowship to become Advanced TEE certified but an Anesthesia Nurse will need 2 weeks and a Valley Review Course. Sounds fair to me.

 

[BLADEMDA]

The nursing school and medical school are separate. If a hospital refused to train it's university CRNAs there would likely be a mandate from Dean to Dean to train them. Even if they stopped, they would just go across town. Even if the university programs closed CRNA schools, they would just go to a CRNA mill. There is no stopping them. The answer lies within your state, and if that fails, your hospital. When that fails, the real data will be available eventually, though they're not going to be studying it. We will look back on these days as the golden age of medicine, from our ocean view condo in Sydney.
Anyone committed to anesthesia not doing a fellowship is taking a big gamble, and even that may not be enough eventually.

I agree 100%. I take no satisfaction in posting this thread. During my Residency the Attendings used to laugh at the notion that the CRNAs/AANA would take over the field. I bet they aren't laughing any more.

I can only imagine the strides the AANA will make in the next 20 years. Unless the brain trust of this field comes up with something in the next 5 years I don't see this Medical Specialty in the USA as much more than a niche as it concerns U.S. Allopathic graduates. When (not if) it becomes obvious to the U.S. Allopathic student that the field is Nursing and FMGs it will be the seal of death.

 

[BLADEMDA]

Park Ridge, Ill.— There are no differences in patient outcomes when anesthesia services are provided by Certified Registered Nurse Anesthetists (CRNAs), physician anesthesiologists, or CRNAs supervised by physicians, according to the results of a new national study conducted by RTI International. The study, titled “No Harm Found When Nurse Anesthetists Work Without Supervision by Physicians,” appears in the August issue of Health Affairs.
The RTI study examined nearly 500,000 individual cases and confirms what previous studies have shown: CRNAs provide safe, high-quality care. The study also shows the quality of care administered is equal regardless of supervision.
Currently, the Centers for Medicare & Medicaid Services (CMS) prohibits Medicare payments to hospitals and ambulatory surgery centers when CRNAs provide anesthesia care in the absence of physician supervision. However, starting in 2001 CMS began allowing states to “opt out” of the Medicare physician supervision requirement for CRNAs. Since then 15 states—most recently California in 2009—have opted out.
The RTI findings demonstrate that the Medicare physician supervision rule for CRNAs is obsolete and unnecessary. The study compared patient outcomes in states where the supervision requirement is in place with patient outcomes in the 14 states that had opted out of the requirement between 2001 and 2005, and found that patient outcomes did not differ. “We find no evidence that opting out of the oversight requirement harms patients in any way,” said study author Jerry Cromwell, PhD. “Based on these findings we recommend that CMS repeal the supervision rule.”​

 

[BLADEMDA]

Study Shows CRNA-Only Anesthesia Delivery Most Cost Effective
Data Show No Difference in Quality or Safety by Anesthesia Provider or Delivery Model​

Park Ridge, Ill.—A Certified Registered Nurse Anesthetist (CRNA) acting as the sole anesthesia provider is the most cost effective model of anesthesia delivery, according to a new study conducted by Virginia-based The Lewin Group and published in the May/June 2010 issue of the Journal of Nursing Economics.
The study, titled “Cost Effectiveness Analysis of Anesthesia Providers,” considered the different anesthesia delivery models in use in the United States today, including CRNAs acting solo, physician anesthesiologists acting solo, and various models in which a single anesthesiologist directs or supervises one to six CRNAs. The results show that CRNAs acting as the sole anesthesia provider cost 25 percent less than the second lowest cost model. On the other end of the cost scale, the model in which one anesthesiologist supervises one CRNA is the least cost efficient model.
The study’s authors also completed a thorough review of the literature that compares the quality of anesthesia service by provider type or delivery model. This review of published studies shows that there are no measurable differences in quality of care between CRNAs and anesthesiologists or by delivery model.
“The data confirm that CRNAs deliver anesthesia safely and cost-effectively,” said AANA President James Walker, CRNA, DNP. “With growing demands on the healthcare system nationwide, we must do all we can to make sure the nation’s healthcare professionals are used as effectively and efficiently as possible. CRNAs, who administer approximately 32 million anesthetics to patients in the United States each year, stand ready to do our part.”
The results of the Lewin study were particularly compelling for people living in rural and other areas of the United States where anesthesiologists often choose not to practice for economic reasons. The safe, cost-effective anesthesia care provided by nurse anesthetists has been a mainstay in these areas for more than 100 years, ensuring millions of patients access to surgical, obstetrical, trauma stabilization, and diagnostic procedures.

 

[BLADEMDA]

The time has come to forget "political correctness" and take the fight to the AANA. The ASA needs to sponsor studies showing the number of "interventions" in CRNA cases at our major medical centers. Take ASA 3 and 4 cases and show the "problems" that the CRNAs fail to adequately address without attending intervention. From intubation, double lumen tube placement, lack of skill for line placement, bronchospasm, etc. the data exists which will clearly show that CRNAs lack the skill and knowledge as a group to practice solo.

The time has long past to "prove" in an ASA backed study that Solo CRNA is both dangerous and costly in terms of morbidity/consultations. The militant AANA must be countered or the war is lost.

As an ASA member I strongly encourage a "mock" administration of our past year's Written and Oral Boards to a select Group of 100 newly minted CRNAs. These CRNAs should have taken the AANA Union Board exam within the last 30-45 days so the anesthesia nurses can't say the CRNAs weren't prepared. Then, publish the results of that study. In addition, a study needs to be done using our computer data based listing "interventions" with CRNA care in anesthetics. I am begging those in power to take action now while there is still time for this specialty.

I hope there is still suifficient time and energy left to save this Medical Specialty from the Community College Graduate with a Bridge degree.

 

[BLADEMDA]

this issue of Anesthesiology, Arbous et al.1 provide a jolting report on the positive impact that anesthesia providers can have on their patients. How? Simple anesthetic management principles seem to have a major effect on perioperative mortality. The routine use of an equipment checklist (odds ratio, 0.61), direct availability of an anesthesiologist to help lend a hand or troubleshoot when needed (odds ratio, 0.46), the use of full-time compared with part-time anesthesia team members (odds ratio, 0.41), the presence of two members of the anesthesia team at emergence (odds ratio, 0.69), and reversal of muscle relaxants at the end of anesthesia (odds ratio, 0.10) had dramatic, positive effects that were associated with reduced perioperative mortality within 48 h after surgery and anesthesia.
This report is remarkable in several ways. First, it is one of the few that have shown anesthetic management processes to dramatically reduce perioperative mortality. Second, it reports perioperative mortality rates matching a number of recent reports. Importantly, it supports the recent insightful article by Lagasse2 about perioperative mortality and his suggestion that the US anesthesia community may have overestimated its impact on improving patient safety in the past two decades. Finally, the authors have used a unique and thoughtfully planned multiinstitutional survey and case-control methodology to evaluate this low (but not low enough)-frequency outcome.
It should not be surprising that perioperative anesthetic management processes can make a difference. The US Federal Aviation Administration has long required the use of pilot checklists for evaluating the airworthiness of aircraft and starting procedures, a requirement strongly supported by outcomes of real and simulated air flight. Why would our specialty, so often compared to piloting, be different? The Federal Aviation Administration also requires two pilots for most commercial aircraft operations, nicely matching the report's finding that the presence of two anesthesia providers at emergence is associated with lower perioperative mortality. The positive impacts of immediate availability of an anesthesiologist when needed and continuity of anesthesia providers in the care of individual patients likewise make sense but, until this study, rarely have been shown to be associated with reduced perioperative mortality.
Have we really overestimated our positive impact on patient safety? Clearly, a number of recent studies suggest that our oft-quoted estimate of 1:200,000 or more patients who have an anesthetic-related death may be flawed.2 The basis for this estimate is accurate but usually misinterpreted. Eichhorn et al.3 reported this low rate of anesthetic-related mortality in healthy patients, an important distinction occasionally neglected in anesthesia patient safety statements. This current study, like others, suggests that the anesthetic-related mortality rate is still too high. The good news is that we have room for improvement and, now, data to support anesthetic management changes that may help.
The study of rare medical events is extremely difficult; it often is extraordinarily frustrating to obtain numerators large enough or denominators that are sufficiently robust to allow calculation of frequencies of the events and subsequent analyses for potential risk factors. Arbous et al.1 have used a multiinstitutional study technique common to clinical research in other medical specialties, notably cardiology, but infrequently attempted in anesthesiology and the study of perioperative mortality. This process has provided the authors with (unfortunately) a sufficient number of perioperative deaths to allow case-control analyses, a good way to seek associations between rare events and potential risk factors.
In general, efforts to seek associations between rare medical events and potential risk factors follow a progression. First, case reports and small case series describe unusual outcomes. If enough of these unusual outcomes can be gathered (typically at least 20 are needed, assuming valid controls can be assessed), a case-control methodology can be used to seek possible but not proven risk factors. Subsequently, potential risk factors identified by case-control studies must be evaluated prospectively in large populations to ascertain their validity. Finally, potential interventions to decrease the frequency of these rare events can be tested in randomized, prospective trials. The current study's elegant methodology takes advantage of the large numbers of perioperative death reports that they collected in multiple institutions by creatively and prospectively seeking data from randomly selected controls within each of those institutions. This methodology is applicable to many rare perioperative events and should be a model often copied in the future.
Although conclusions from one study should not lead to wholesale changes in practice, the findings in this study support many plausible assumptions that improvements in anesthetic management processes can positively influence patient outcomes. The use of equipment checklists, immediate availability of anesthesiologists to help when needed, especially to provide extra assistance at emergence from anesthesia, and routine reversal of muscle relaxants are processes that should be seriously considered when seeking opportunities to improve the perioperative outcomes of anesthetized patients.
Mark A. Warner, M.D.
Mayo Clinic College of Medicine, Roches-ter, Minnesota. [email protected]

Back to Top | Article Outline
References

1. Arbous MS, Meursing AEE, van Kleef JW, de Lange JJ, Spoormans HHAJM, Touw P, Werner FM, Grobbee DE: Impact of anesthesia management characteristics on severe morbidity and mortality. Anesthesiology 2005; 102:257-68
Cited Here... | View Full Text | PubMed | CrossRef

2. Lagasse RS: Anesthesia safety: Model or myth? A review of the published literature and analysis of current original data. Anesthesiology 2002; 97:1609-17
Cited Here... | View Full Text | PubMed | CrossRef

3. Eichhorn JH: Prevention of intraoperative anesthesia accidents and related severe injury through safety monitoring. Anesthesiology 1989; 70:572-7
Cited Here... | View Full Text | PubMed | CrossRef

 

[sevoflurane]

Until the dust settles... which may not be in the foreseeable future, here are a couple of thoughts to graduating residents:

1. Get as much $$ as you can while the getting is hot. Work hard... you are used to it... so who cares? If you are bringing in a bigger pay check, then you can knock down your debt and feel economic stresses in your life gently roll off your back. The current milieu will not last forever. You will feel change next year.
2. Immediate partnership or at the most 1 yr. to partnership (with no more than 15% skimmed off the top). Even better = 1099. Some Dallas groups want 3 yrs. Don’t get used during these times.
3. Be responsible. Again, pay off your debts. Save the M3 or the Benz for later.
4. Avoid supervising for 3-4 years. Become a master at solo anesthesia.
5. Max out your retirement fund.
6. When obamacare/CRNA BS hits you, have a good chunk of change in the bank so that you can walk into a practice happy with a 300k salary.
7. Keep up your skills. Grow as a provider: understand the red tape, sit on committees, be involved in the inner workings of your group/hospital. Learn how to negotiate contracts. They don't teach some of that stuff in residency. It must be learned. Gain and keep up the skills that will differentiate you from a CRNA/AA. Do not become an automaton.

Sevo debt 50K from 275K one year ago. Happy with my decisions despite the fact that I don’t live in the rockies or the beach. I’m young and have plenty of time to get there.

My 2 cents.

 

[BLADEMDA]

Until the dust settles... which may not be in the foreseeable future, here are a couple of thoughts to graduating residents:

1. Get as much $$ as you can while the getting is hot. Work hard... you are used to it... so who cares? If you are bringing in a bigger pay check, then you can knock down your debt and feel economic stresses in your life gently roll off your back. The current milieu will not last forever. You will feel change next year.
2. Immediate partnership or at the most 1 yr. to partnership (with no more than 15% skimmed off the top). Even better = 1099. Some Dallas groups want 3 yrs. Don’t get used during these times.
3. Be responsible. Again, pay off your debts. Save the M3 or the Benz for later.
4. Avoid supervising for 3-4 years. Become a master at solo anesthesia.
5. Max out your retirement fund.
6. When obamacare/CRNA BS hits you, have a good chunk of change in the bank so that you can walk into a practice happy with a 300k salary.
7. Keep up your skills. Grow as a provider: understand the red tape, sit on committees, be involved in the inner workings of your group/hospital. Learn how to negotiate contracts. They don't teach some of that stuff in residency. It must be learned. Gain and keep up the skills that will differentiate you from a CRNA/AA. Do not become an automaton.

Sevo debt 50K from 275K one year ago. Happy with my decisions despite the fact that I don’t live in the rockies or the beach. I’m young and have plenty of time to get there.

My 2 cents.

Good post

 

[lakersbaby]

what is going on with this lawsuit?

http://www.anesthesiologynews.com/index.asp?ses=ogst&section_id=3&show=dept&article_id=14427

 

[dhb]

I agree with you Sevo except i'm not convinced having debt is a bad thing in this inflationary environment.I do agree that it's wise to save up the money but i wouldn't rush to pay down low interest student loans.
Save the money, put it in a secure investment: short term bonds and pay back those loans slowly knowing that you are able to pay them back.

Europe is still very conservative regarding this issue most people would cringe at the idea that a nurse is delivering the anesthesia solo. However Europe always lags the US so this could be a possibility in the coming decades.

A remember a study published in Anesthesiology not too long ago that showed no difference between providers on simulated clinical scenarios (airway obstruction , hyperK etc..). Unfortunately i think this is what MMD was trying to get to and that is that if a new paradigm is necessary to weed out the lesser MDs than so be it. MDs will always be needed and the cream always rises to the top.

And for those who dread "socialized medicine" i can tell you that in Europe a lot of MDs make the same of more than their US counterparts while getting more out of their taxes: free school less expensive health care etc...

 

[Coastie]

Just called the ASA regarding the CRNA article.

They told me that ASA Pres talked to the Boston Globe today about it:

http://www.boston.com/news/health/blog/2010/08/nurse_anestheti.html

Also told me that they will forward a response to my personal email, which they told me to feel free to distribute.

Here we go...





August 3, 2010


Dear Member,

As you are aware, the American Association of Nurse Anesthetists (AANA) sponsored a study published in Health Affairs August issue titled, "No Harm Found When Nurse Anesthetists Work Without Supervision By Physicians." * I wanted to share with you the work we have done to thwart this misinformation as it enters the public domain.

Leadership has worked with staff to complete a thorough analysis of the study. On Monday, August 2, 2010, I had the opportunity to provide ASA's perspective on the study to the Boston Globe's Elizabeth Cooney who writes the column "White Coat Notes". * You can read the story "http://www.boston.com/news/health/blog/2010/08/nurse_anestheti.html"here.

The following is an overview of the points we discussed from ASA's analysis with the reporter as key shortcomings of the study, with which you should be familiar in case this issue arises:
The study's methodology relies on billing data: *****
*****
QZ modifier overstates independent practice because paperwork and documentation reduced for anesthesiologist who may report anesthesiologist directed care with this billing modifier. Even in the absence of an anesthesiologist, a surgeon is present and providing medical input into the patient's care; characterizing this as "independent" CRNA practice misrepresents the actual nature of the care delivered.

The study reviews about 480,000 cases that would have a predicted anesthesia related mortality in 2 cases: analysis of anesthesia related mortality is grossly underpowered.

Billing data does not permit distinguishing between surgical and anesthesia complications or mortality.

Anesthesiologists' advances in patient safety must be preserved. *Recent data showed one death per 200,000-300,000 anesthetics administered. (Committee on Quality of Healthcare in America, Institute of Medicine: To Err is Human, Building a Safer Health System. *Edited by Kohn L, Corrigan J, Donaldson M. *Washington, National Academy Press, 1999, p 241)

Anesthesiologists not only care for patients undergoing the most complex procedures (base unit differential) but also the sicker patients undergoing all procedures (unrecognized selection bias). *These considerations would suggest dramatically better outcomes for CRNAs, but this is not seen. *In fact, CRNA only cases (QZ) actually showed worsening mortality and complications, while other groups improved (see tables below).

Even equivalent outcomes with lower risk cases would be a troubling finding. And the most significant improvement in mortality and complications took place in the ACT model of practice, further supporting the value of anesthesiologists' involvement in care. *
(Reference Silber 2000 study: *>6 excess deaths/1000 cases from failure to rescue from surgical or anesthetic complication in absence of anesthesiologist)


From Table 4 in Dulisse & Cromwell:

MORTALITY
Non Opt Out
Pre Opt Out
Post Opt Out
% Change
MD
1
0.797
0.788
-1.13%
CRNA
0.899
0.651
0.689
5.84%
Team
0.959
0.708
0.565
-20.2%

*
COMPLICATIONS
Non Opt Out
Pre Opt Out
Post Opt Out
% Change
MD
1
0.824
0.818
-0.73%
CRNA
0.992
0.798
0.813
1.88%
Team
1.067
0.927
0.903
-2.59%
*
Cost of care is equivalent under Medicare and Medicare-based payment systems. Characterizing independent CRNA practice as "cost effective" misrepresents the facts.

The study understates differences in the training of anesthesiologists and nurse anesthetists – nurse anesthetists 2 yrs post baccalaureate, anesthesiologists 8 yrs, including a broad foundation in general medicine, intensive care, and pain management.

Overwhelming public preference for physician supervision of anesthesia care (>75%) (Tarrance 2001). Public policy should reflect this preference.

The study is funded by the American Association of Nurse Anesthetists and like many prior studies conducted by Dr. Cromwell under contract to AANA, adheres to AANA's public policy agenda.

Anesthesiology has enjoyed enormous success in recent years in media exposure of the role of the anesthesiologist. This coverage has appeared on the most prominent and prestigious outlets in the world including the New York Times, Wall Street Journal, CNN to name a few. We will be unrelenting in promoting the expertise of the anesthesiologist and our rightful place leading perioperative care. Each of us has the opportunity to deliver this message through our actions and through our words with the hundreds of patients for whom we each care annually. Both in the press and at the bedside, we mustn't miss an opportunity to educate and inform the public about the specialty.
Sincerely yours,
Alexander A. Hannenberg, M.D.
President

 

[gaspasser2004]

Everyone seems to know "someone" who is doing anesthesia and raking in BIG bucks. I'm talking 500K+. This can't last forever. However, I think that MD's will be needed and rewarded reasonably for the forseeable future.

All Politics is Local
So the AANA comes out with a flawed study that shows MD=CRNA? Try convincing surgeons and patients in an educated, entitled metropolitan area that they should get their anesthesia from independent CRNA's. Not going to happen. The "Mad Men" themselves couldn't create an ad campaign that would allow this.

CRNA's are making things difficult for themselves
Believe it or not, but the CRNA labor market is tightening up. Older CRNA's are delaying retirement due to stock market losses. Newer CRNA's are being churned out by the CRNA mills faster than jobs can be created for them. My institution for the first time in years has more CRNA's looking for jobs than there are jobs available.

The future of anesthesia is the care team model
Eventually, solo MD anesthesia will be a thing of the past. The model of 4:1 may change to 5:1 or 6:1. I envision anesthesiologists and nurses working together to care for patients in the operating room much like physicians and nurses take care of patients together in the ICU. The physician is the ultimate decision maker, but relies on the nurses to get the work done.

 

[loveoforganic]

300k a year for how many hours? That hardly sounds like a low enough number to be pissed off about "settling" for. The whole "make a lot of money now so you can survive on 300k later" deal just sounds silly.

 

[vancouvergeorge]

300k a year for how many hours? That hardly sounds like a low enough number to be pissed off about "settling" for. The whole "make a lot of money now so you can survive on 300k later" deal just sounds silly.

Most surgeons don't even make $300k now.... imagine after health care reform.

 

[bronx43]

Most surgeons don't even make $300k now.... imagine after health care reform.

Most people automatically equate health care reform with equally big cuts across the board, but that's hardly the case. General surgeons will still likely pull between $250k and 300k. However, the more lucrative specialties will probably be brought back down to earth. Primary care might actually get a little boost in their reimbursement.

 

[BLADEMDA]

Everyone seems to know "someone" who is doing anesthesia and raking in BIG bucks. I'm talking 500K+. This can't last forever. However, I think that MD's will be needed and rewarded reasonably for the forseeable future.

All Politics is Local
So the AANA comes out with a flawed study that shows MD=CRNA? Try convincing surgeons and patients in an educated, entitled metropolitan area that they should get their anesthesia from independent CRNA's. Not going to happen. The "Mad Men" themselves couldn't create an ad campaign that would allow this.

CRNA's are making things difficult for themselves
Believe it or not, but the CRNA labor market is tightening up. Older CRNA's are delaying retirement due to stock market losses. Newer CRNA's are being churned out by the CRNA mills faster than jobs can be created for them. My institution for the first time in years has more CRNA's looking for jobs than there are jobs available.

The future of anesthesia is the care team model
Eventually, solo MD anesthesia will be a thing of the past. The model of 4:1 may change to 5:1 or 6:1. I envision anesthesiologists and nurses working together to care for patients in the operating room much like physicians and nurses take care of patients together in the ICU. The physician is the ultimate decision maker, but relies on the nurses to get the work done.

The AANA is ANTICIPATING the change to a 6-8:1 model so they are getting a running start at producing the manpower needed to fill the slots. The AANA strategy is "build it and they will come" approach to new graduates. The AANA won't risk losing market share to AAs and has decided to keep pushing the "junk science" articles to keep the heat on the ASA. Solo practice is the ultimate goal but the interim goal is 6-8:1 with minimal supervision. This means MD (A)s get displaced out of work or retire while the CRNA steps in to take his/her place. So, unless the ASA steps up to the plate with thousands more AAs PLUS new legislative efforts to eradicate TEFRA the AANA strategy is a sound one. The only caveat to the AANA plan is a reduction/halt to CRNA salaries for the foreseeable future.

 

[BLADEMDA]

The ASA response should be a controlled study comparing newly minted AANA Board exam performance with the Anesthesiology written Boards.

NEwly minted CRNAS should obtain their AANA Board performance (%) and then sit for the ABA written exam. The scores should then be correlated and a % based on the reference Group (allopathic or U.S. Medical School graduates)
assigned to the CRNA. Then, publish the results.

My hypothesis is that 50% of newly minted CRNAs would fail the exam outright and another 25% would be on the fence. THe next study should administer an Oral Exam to the 25% or so of CRNAS who may pass the written exams. Again, another 50% would fail. This would leave less than 1/4 of all CRNAs capable of passing our BASIC COMEPETENCY EXAMS.

Now, the numbers could even be better for us and worse for them as MACEO, et al would claim. The only way to know is to test 100-200 newly minted CRNAs with a Broad range of AANA Board exam scores.

You can count on my financial contribution for such a study.

 

[Coastie]

Why allow them to sit for an exam that they don't qualify for?

Let's have em sit for USMLE 1,2,3, and then ABA written/orals...

After they finish medical school.

We gotta play hardball, and I don't know if your proposed study is the way to do it..

The ASA response should be a controlled study comparing newly minted AANA Board exam performance with the Anesthesiology written Boards.

NEwly minted CRNAS should obtain their AANA Board performance (%) and then sit for the ABA written exam. The scores should then be correlated and a % based on the reference Group (allopathic or U.S. Medical School graduates)
assigned to the CRNA. Then, publish the results.

My hypothesis is that 50% of newly minted CRNAs would fail the exam outright and another 25% would be on the fence. THe next study should administer an Oral Exam to the 25% or so of CRNAS who may pass the written exams. Again, another 50% would fail. This would leave less than 1/4 of all CRNAs capable of passing our BASIC COMEPETENCY EXAMS.

Now, the numbers could even be better for us and worse for them as MACEO, et al would claim. The only way to know is to test 100-200 newly minted CRNAs with a Broad range of AANA Board exam scores.

You can count on my financial contribution for such a study.

 

[pgg]

You can count on my financial contribution for such a study.

And you can count on exactly 0 CRNAs to sign up as subjects for such a study.

(Would YOU sign up as a subject in a study run by the AANA?)

 

[Taurus]

I smell somebody has an agenda. CRNA's just as good as anesthesiologists? Foreign-trained doctors just as good as American-trained ones (at least foreign-trained ones would be better than DNP's)? It's obvious what the agenda is.

Foreign-trained docs as good as U.S. physicians
Study: Patients treated by doctors born, trained overseas had lowest death rate

WASHINGTON — Physicians trained in other countries provide care just as good as U.S. doctors, according to new report published Tuesday in the journal Health Affairs.

"Despite a rigorous U.S. certification process for international graduates, the quality of care provided by doctors educated abroad has been an ongoing concern," said John Norcini, president of the Foundation for Advancement of International Medical Education and Research, who led the study.

Norcini's team analyzed 244,153 hospitalizations of patients with congestive heart failure or acute heart attack in Pennsylvania who were treated by either a U.S.-trained or foreign-trained doctor.

Patients of foreign-born international medical graduates had the lowest death rates. Patients of U.S. citizens who attended medical school in other countries had the highest death rates. U.S.-born and trained doctors fell in the middle.

"These findings bring attention to foreign-trained doctors and the valuable role they have played in responding to the nation's physician shortage," Norcini said.

"It is reassuring to know that patients of these doctors receive the same quality of care that they would receive from a physician trained in the United States."

He said 25 percent of all doctors practicing in the United States are educated abroad.

The study also found that experience did not always mean the best care. The longer it had been since a doctor left medical school, the worse the rate of death and complications requiring patients to stay in the hospital longer.

"Ongoing training programs and periodic reassessment of doctors' knowledge and skills can help maintain the level of physician competence needed to deliver high quality health care," Norcini said.

A second study, also published in Health Affairs, found nurse anesthetists can safely provide care without doctors supervising them.

The two reports suggest ways to help provide care to more Americans at potentially lower cost, just as healthcare reform promises to extend health coverage to millions who do not have it.

"Nurse anesthetists get essentially the same training in anesthesia as anesthesiologists. So in this case, a nurse is just about a perfect substitute for the doctor," Jerry Cromwell, a health economist at the Research Triangle Institute in North Carolina who led one study, said in a statement.

"Eliminating physician supervision will not only allow nurses to do what they are trained and highly qualified to do, but it will encourage hospitals and surgeons to use a more cost-effective mix of anesthetists."

Nurse anesthetists typically earn less than anesthesiologists, who are medical doctors.

Cromwell and colleague Brian Dulisse analyzed 481,440 hospitalizations covered by Medicare, the federal health insurance plan for the elderly. While more nurse anesthetists cared for patients during surgery between 1999 and 2005, there was no increase in bad outcomes.

About 46 million Americans, or 15 percent of the population, now have no health insurance. A new healthcare law signed in March is projected to extend coverage to 32 million more Americans, mainly by requiring them to buy it.

Many groups worry the already stretched medical system will be unable to accommodate so many more people seeking regular health care services.
​

 

[BLADEMDA]

And you can count on exactly 0 CRNAs to sign up as subjects for such a study.

(Would YOU sign up as a subject in a study run by the AANA?)

The militant Nurses are always claiming they are "equivalent" to a Board Certified Anesthesiologist. Let them enter the study and validate the claim.
Never underestimate the arrogance of a militant anesthesia nurse.

 

[cfdavid]

you don't go into pediatric endocrinology to get rich. yet, many still choose that path. same with rheumatology. they don't make a lot of money, generally, but they can earn a healthy living.

go into anesthesiology if you're interested. like others have said, we need good people in this field, and we can set the record straight.

cf

 

[Anesdawg]

aana website has a link to the article

http://www.aana.com/optoutstudy/

Here is a link to the article.......

http://content.healthaffairs.org/cg...ey=ezh7UYKLtCyLY&keytype=ref&siteid=healthaff

JOIN THE ASA; donate to the ASAPAC!!!!!!!!!!!!

 

[kazuma]

Other specialties are more secure for those with an interest in them. I also won't lose sleep working for 225k if it comes to that. If you are coming in looking for >400, you're going to probably be disappointed. Of course all physician salaries will almost certainly decline. I expect no raises to counter cost of living increases, and significant reimbursement decline as well, toward Medicaid levels, which might actually rise.

Sorely disappointed indeed. In fact, I know a dozen or so 4th year students applying to anesthesia and not a single one believes they won't be making at least $300K/yr. They look at me with sparkling dollar signs in their eyes when they describe the "good lifestyle" they are yearning for and that BMW they have their heart set on. They can't comprehend the idea that future anesthesiologists could very well be making $150-225K/yr within the next decade or so. I believe this is a very real and likely possibility.

Honestly, I believe everyone that is currently applying to anesthesiology should go into this with no expectations of earning more than $175-225K. It will likely save you a lot of frustration, disappointment and hatred towards the field when shiz hits the fan 5-10 years down the road.

 

[BLADEMDA]

Sorely disappointed indeed. In fact, I know a dozen or so 4th year students applying to anesthesia and not a single one believes they won't be making at least $300K/yr. They look at me with sparkling dollar signs in their eyes when they describe the "good lifestyle" they are yearning for and that BMW they have their heart set on. They can't comprehend the idea that future anesthesiologists could very well be making $150-225K/yr within the next decade or so. I believe this is a very real and likely possibility.

Honestly, I believe everyone that is currently applying to anesthesiology should go into this with no expectations of earning more than $175-225K. It will likely save you a lot of frustration, disappointment and hatred towards the field when shiz hits the fan 5-10 years down the road.

You people are missing a very important point. The only way to maintain Physician level income is to maintain a Physician Specialty. How do you plan on doing that when Advanced Anesthesia Nurses claim equivalence in all aspects of this NURSING field? Why in the world should the govt. pay Anesthesiology Attendings a Physician level wage when an Advanced Nurse with a DNAP will do the job for $90K? Maybe, the govt. just allows FMG trained Anesthesiologists to do a one year AANA fellowship and "collaborate with his/her colleagues." These FMGs get a certificate and Board exam from the AANA then get paid 120K by the govt.

Money is NOT the issue. Either we save the Medical Specialty of Anesthesiology or the Anesthesia Nurses get this field as Nursing level duty.
The days of getting the best of both worlds are coming to an end.

 

[BLADEMDA]

 

[BLADEMDA]

I told you years ago that there was a war going on in this field. Most of you mocked and attacked me. Few saw the threat the AANA was posing to the specialty. I came on SDN to warn and prepare you for the onslaught that was to come. I urged (and still do) that one should strongly consider a fellowship to distinguish your credentials from that of a CRNA with DNAP. It is my belief that the many heard about or read my posts so fellowship applications are at an all time high.

Now, I urge every ASA member to ask their Chair or Attending to join in the struggle to save our beloved specialty from destruction. We have but a few years remaining to convince lawyers/legislators views that this field should not be turned over to SOLO Anesthesia Nurses. We still have the major medical centers and the resources to win; but, do we have the vision, courage and leadership?

Blade
Fighting Against the AANA
Help Save the Medical Specialty of Anesthesiology

 

[cfdavid]

You people are missing a very important point. The only way to maintain Physician level income is to maintain a Physician Specialty. How do you plan on doing that when Advanced Anesthesia Nurses claim equivalence in all aspects of this NURSING field? Why in the world should the govt. pay Anesthesiology Attendings a Physician level wage when an Advanced Nurse with a DNAP will do the job for $90K? Maybe, the govt. just allows FMG trained Anesthesiologists to do a one year AANA fellowship and "collaborate with his/her colleagues." These FMGs get a certificate and Board exam from the AANA then get paid 120K by the govt.

Money is NOT the issue. Either we save the Medical Specialty of Anesthesiology or the Anesthesia Nurses get this field as Nursing level duty.
The days of getting the best of both worlds are coming to an end.

Blade, that all may be true. I appreciate an advanced warning, as I do in all situations.

But, let this forum stand as a little microcosm of the types of people entering the field. Perhaps more than ever (and I know this issue has been going on for a long time), residents and med students are very well informed about the threat (very real) of mid-levels to this medical specialty. Sure, in 1985, there may have been "rumors" of AANA lobbying, but in today's world, information flows. We've all read posted threads which can reach anyone and everyone. So, it really is different. Have faith, though. With veterans such as yourself willing to fight, and newcomers like many of us, we can put the field back into equillibrium.

This threat need not exist, were it not for the militarism and outright antagonism coming from the AANA as well as some CRNA's. But, with the ongoing onslaught of propaganda by the AANA, it is. So, we'll act accordingly.

cf

 

[BLADEMDA]

Blade, that all may be true. I appreciate an advanced warning, as I do in all situations.

But, let this forum stand as a little microcosm of the types of people entering the field. Perhaps more than ever (and I know this issue has been going on for a long time), residents and med students are very well informed about the threat (very real) of mid-levels to this medical specialty. Sure, in 1985, there may have been "rumors" of AANA lobbying, but in today's world, information flows. We've all read posted threads which can reach anyone and everyone. So, it really is different. Have faith, though. With veterans such as yourself willing to fight, and newcomers like many of us, we can put the field back into equillibrium.

This threat need not exist, were it not for the militarism and outright antagonism coming from the AANA as well as some CRNA's. But, with the ongoing onslaught of propaganda by the AANA, it is. So, we'll act accordingly.

cf

The Medical Specialty has 5-8 years left unless CONCRETE studies are forthcoming disputing the AANA propaganda. Time is running out on the ASA and its leadership. With just one or two additional laws CMS can forever alter this soon to be field of Nursing.

 

[BLADEMDA]

The Medical Specialty has 5-8 years left unless CONCRETE studies are forthcoming disputing the AANA propaganda. Time is running out on the ASA and its leadership. With just one or two additional laws CMS can forever alter this soon to be field of Nursing.

If and When CMS/Federal govt. defacto declare this field NURSING LEVEL work why should anyone working in it earn a Physician level wage? Why pay an Advanced Practice Nurse or its Equivalent more than a Board Certified Family Physician? Why should Nursing level duties be reimbursed at a higher level than Physicians?

That will be the bitter pill the AANA must eventually swallow. However, the leadership is determined to win the war (Anesthesia is Nursing and CRNAs should work Solo) whatever the cost.

So, unless you want to possibly end up as a Glorified Anesthesia Nurse don't go into the field of Anesthesiology. The ASA has failed miserably to address this growing problem/threat and it is only geting bigger by the day (as evidenced by 2 new AANA studies over the past 90 days).

 

[kazuma]

You people are missing a very important point. The only way to maintain Physician level income is to maintain a Physician Specialty. How do you plan on doing that when Advanced Anesthesia Nurses claim equivalence in all aspects of this NURSING field? Why in the world should the govt. pay Anesthesiology Attendings a Physician level wage when an Advanced Nurse with a DNAP will do the job for $90K? Maybe, the govt. just allows FMG trained Anesthesiologists to do a one year AANA fellowship and "collaborate with his/her colleagues." These FMGs get a certificate and Board exam from the AANA then get paid 120K by the govt.

Money is NOT the issue. Either we save the Medical Specialty of Anesthesiology or the Anesthesia Nurses get this field as Nursing level duty.
The days of getting the best of both worlds are coming to an end.

I couldn't agree more. I've met dozens of CRNA's that truly believe their training is equal, if not better than MD/DO training. Several of them believe they have better skills than MD/DO's since their supervising attending often times just pokes his head into the room and gives them the nod to go ahead and start the case instead of working in the room from start to finish.

You're right, money is not the issue, however, it is one of the strongest driving forces that influences specialty choice among medical students. There is a reason why many anesthesia programs went unfilled in the 90's only to be met with a recent surge of interested students hoping to get their piece of the pie while anesthesia salaries are at their peak. In fact, money is about the only thing people want to talk about when I mention I'm applying to anesthesiology residency. Heaven forbid someone actually finds the field to be interesting.

I also think that the powers at be won't take this war seriously until it their pocket books take a significant hit and programs start going unfilled. Unfortunately, if they take that long to address the issue, we'll have likely already lost the war.


I've accepted the fact that I may never make more than 150-200K/year as an Anesthesiologist (perhaps less?). What troubles me the most about Anesthesiology is that it is becoming more and more difficult for physicians to do their own cases. How am I suppose to practice and fine tune my skills and become a proficient provider after residency if I'm spending all day supervising CRNA's and doing pre-op evals?

 

[cfdavid]

The Medical Specialty has 5-8 years left unless CONCRETE studies are forthcoming disputing the AANA propaganda. Time is running out on the ASA and its leadership. With just one or two additional laws CMS can forever alter this soon to be field of Nursing.

Mid-level's are a fact of life in the U.S. How it all happened, I'm not sure. How did it get out of hand, we can speculate. But, it is what it is.

Mid-levels abound in every hospital. They work in the ICU, OR (both sides of the drape), and in outpatient clinics. They deliver babies. The list goes on as for as long as the list of medical specialties.

Sure, anesthesiology has a particular challenge. But, so do other medical specialties. The key is to become leaders in the medical specialty of anesthesiology. We'll need to adapt to changing economic drivers, and find creative ways to build a case against them. I seriously may put some time into this, I just don't know when.

As more and more encroachment becomes evident (for the very same blindfold reasons it happened in our specialty) in other fields, this fight will be joined by other physicians. And even if it's not, we can still solve our problems in-house, IMO.

There are many interesting ways in which the field can progress, even under these serious threats. MilMD has said for years that it's unlikely that anes docs are stool-sitting case to case in the future. This is o.k. as long as we ADD value to the chain in other ways.

Will we need to adjust skill sets? Be a bit more protective of procedures we "farm" out to CRNA's? We'll need to make lots of little changes. And, let's not forget to look in the mirror. MD/DO's have had a big role in this, whether it be "letting the CRNA do the spinal" because they could get more sleep during in-house call or whatever. I don't go back that far.

We WILL need to adjust, though. Each anesthesiology resident will need to go to work/training with the knowledge that a mid-level provider near them wants their job. So, they'll NEED to be better. We'll NEED to offer additional value to the value chain. I don't think this is that difficult, really.
This is a scenario where, literally, every man/woman counts as we redefine ourselves in challenging economic times (and it's ALL about economics...)

cf

 

[midazme]

some very good arguments here about why the study is ridiculous.

has anyone posted their thoughts on the original story's comments section? i feel too often we get all worked up in our little forum and don't actually go out and bash these lame ass articles where they're actually posted.

i wonder if that's why everyone's always saying 'anesthesiologists need to stand up and do something', but it seems like no one does. all politics is local, and my at my hospital we've just engineered an anesthesia resident take over of the resident house staff. we're also making inroads with the state anesthesia medical society. i think the residents in Alabama have the most active political arm...i'd love to hear their thoughts on how to effect change.

 

[Paseo Del Norte]

Unfortunately, it has been allowed to become an aggressive and dare I say militant culture. Many people are now entering nursing with no other goal in mind other than either NP or CRNA. This behaviour is not only allowed but it is encouraged and no one has done anything to blunt or regulate it.

In fact, I cannot tell you guys the amount of shyte, ridicule and in some cases disdain thrown my way when other nurses find out that I choose to go into respiratory therapy rather than pursue advanced practice nursing.

 

[BLADEMDA]

Mid-level's are a fact of life in the U.S. How it all happened, I'm not sure. How did it get out of hand, we can speculate. But, it is what it is.

Mid-levels abound in every hospital. They work in the ICU, OR (both sides of the drape), and in outpatient clinics. They deliver babies. The list goes on as for as long as the list of medical specialties.

Sure, anesthesiology has a particular challenge. But, so do other medical specialties. The key is to become leaders in the medical specialty of anesthesiology. We'll need to adapt to changing economic drivers, and find creative ways to build a case against them. I seriously may put some time into this, I just don't know when.

As more and more encroachment becomes evident (for the very same blindfold reasons it happened in our specialty) in other fields, this fight will be joined by other physicians. And even if it's not, we can still solve our problems in-house, IMO.

There are many interesting ways in which the field can progress, even under these serious threats. MilMD has said for years that it's unlikely that anes docs are stool-sitting case to case in the future. This is o.k. as long as we ADD value to the chain in other ways.

Will we need to adjust skill sets? Be a bit more protective of procedures we "farm" out to CRNA's? We'll need to make lots of little changes. And, let's not forget to look in the mirror. MD/DO's have had a big role in this, whether it be "letting the CRNA do the spinal" because they could get more sleep during in-house call or whatever. I don't go back that far.

We WILL need to adjust, though. Each anesthesiology resident will need to go to work/training with the knowledge that a mid-level provider near them wants their job. So, they'll NEED to be better. We'll NEED to offer additional value to the value chain. I don't think this is that difficult, really.
This is a scenario where, literally, every man/woman counts as we redefine ourselves in challenging economic times (and it's ALL about economics...)

cf

Yes, you are correct. My post that we only have 5-8 years left was out of line and incorrect. It will take another 2-3 decades for the AANA to achieve all of its agenda. I hope we can "adjust" before then.