Dual ACNP/CRNA

[rdh218]

I am a licensed ACNP, primarily educated in critical care, and a present CRNA student. My end goal is to find a position that would allow me to function in a mid-level anesthesia/critical care type role, with both ICU and OR responsibilities. What are the chances that anyone in the medical community would find value in this type of position?

---

Members don't see this ad.

 

[Fox800]

This should be good.

 

[rdh218]

This should be good.

Feel free to start the berating if you would like.

 

[CCM-MD]

You would probably make almost double the money as an anesthesia midlevel than as an ICU midlevel. Splitting time will mean less pay. Idk why you would want to do that, aside from interest in being in the unit… but if that’s the case idk why you are spending the time and money to become a nurse anesthetist in the first place.

 

[rdh218]

You would probably make almost double the money as an anesthesia midlevel than as an ICU midlevel. Splitting time will mean less pay. Idk why you would want to do that, aside from interest in being in the unit… but if that’s the case idk why you are spending the time and money to become a nurse anesthetist in the first place.

Money isn't really a driving force in the decision; I find both interesting for different reasons. Ideally, I would like to split my time, 70/30 or 60-40, between the OR and somewhere like CV/SICU/Trauma/Neuro Trauma. For me, the additional education seemed like a requirement, even if I had no desire to work in the OR. I feel like I got more from my NP experience than most, given the willingness of several physicians to facilitate my education. At the same time, I am not under any illusion that 2 years and 800 hours is enough to say I'm prepared to care for critically ill patients with any level of independence. Anesthesia complements critical care well, from the medications, management of a wide range of critical illnesses, and procedural skills; after all, it is one of the medical specialties that could apply for critical care fellowship, if I'm not mistaken. Some days, I manage the same patient population that I would see in the unit, just in a slightly different capacity. When I'm done, I will have managed nearly 1000 airways, managed as many vents, placed several more lines, will have been solely responsible for the correction and maintenance of tenuous hemodynamics in hundreds of patients, independently managed a variety of critical disease states, and will have nearly 3000 physician precepted hours between the two certifications. I would argue that I should be more prepared and more useful than most anyone applying for the same mid-level positions.

 

[CCM-MD]

Good luck

 

[SOCalXtine]

Good luck

Not to high jack the thread but just wondering, what things can an MD/DO fellowship trained in CCM can do procedure wise that an NP trained in crit care cannot do ?

 

[Siggy]

Not to high jack the thread but just wondering, what things can an MD/DO fellowship trained in CCM can do procedure wise that an NP trained in crit care cannot do ?

It's not about the mechanical skill. Most critical care procedures honestly aren't that complicated. The why, when, and when not to are the hard parts. It's like the physical act of ordering antibiotics isn't difficult. That's just typing. Now deciding which antibiotics to start and why outside of spamming vanco/zosyn and ID consults is a completely different question.

 

[Siggy]

Money isn't really a driving force in the decision; I find both interesting for different reasons. Ideally, I would like to split my time, 70/30 or 60-40, between the OR and somewhere like CV/SICU/Trauma/Neuro Trauma. For me, the additional education seemed like a requirement, even if I had no desire to work in the OR. I feel like I got more from my NP experience than most, given the willingness of several physicians to facilitate my education. At the same time, I am not under any illusion that 2 years and 800 hours is enough to say I'm prepared to care for critically ill patients with any level of independence. Anesthesia complements critical care well, from the medications, management of a wide range of critical illnesses, and procedural skills; after all, it is one of the medical specialties that could apply for critical care fellowship, if I'm not mistaken. Some days, I manage the same patient population that I would see in the unit, just in a slightly different capacity. When I'm done, I will have managed nearly 1000 airways, managed as many vents, placed several more lines, will have been solely responsible for the correction and maintenance of tenuous hemodynamics in hundreds of patients, independently managed a variety of critical disease states, and will have nearly 3000 physician precepted hours between the two certifications. I would argue that I should be more prepared and more useful than most anyone applying for the same mid-level positions.

Cool... I had 15k hours of physician precepted hours between residency and fellowship... and that's not even counting 3rd and 4th years of medical school.

 

[rdh218]

Cool... I had 15k hours of physician precepted hours between residency and fellowship... and that's not even counting 3rd and 4th years of medical school.

You're comparing apples and oranges. You are assuming I am somehow equating anything I've done to that of a physician, and I'm not. I have no misunderstanding of how my education and clinical time compares to a medical education. My question regarding what I want to do is would physicians see any clinical utility in having someone with both skillsets? Would surgical specialties see any value in someone who could provide anesthesia for their cases and also help with post-operative ICU management? I'm not asking if physicians hate the idea of mid-levels because I know that answer without asking. I'm asking, in a system that is going to utilize mid-levels in anesthesia and critical care roles regardless, would there be any benefit to being able to "function" in both roles?

 

[Siggy]

You're comparing apples and oranges. You are assuming I am somehow equating anything I've done to that of a physician, and I'm not. I have no misunderstanding of how my education and clinical time compares to a medical education. My question regarding what I want to do is would physicians see any clinical utility in having someone with both skillsets? Would surgical specialties see any value in someone who could provide anesthesia for their cases and also help with post-operative ICU management? I'm not asking if physicians hate the idea of mid-levels because I know that answer without asking. I'm asking, in a system that is going to utilize mid-levels in anesthesia and critical care roles regardless, would there be any benefit to being able to "function" in both roles?

So this is a fair question... but one that has zero bearing on hours of experience.


Now I'm not a surgeon, but I'm going to guess the answer to that question is "no." for a variety of reasons.

1. The same issue with any combined multispecialty training. For example, the anesthesiologists who dream of doing cases one day and ICU the next day or EM-CCM who wants to be in the ED one day and ICU the next day. If I'm scheduling people for the ICU and you're full time, then while I might want to accommodate a schedule request, I might not have the ability to do so. What happens if you're scheduled to both cover the ICU and run cases at the same time? It's not like you can up and leave to go to the bedside of a crashing ICU patient.

Now, sure, a surgeon can't up and leave the case either, but that's what normally their midlevel is doing while they're in the case as well as the ICU team.

2. The surgeon doesn't command the anesthesiologist. So what happens when what the surgeon wants to happen in the SICU conflicts with what the anesthesiologist wants to do in the OR?

3. Knowledge is a factor. There's only so much people can retain and when it comes to being an expert in a field, it can be hard to keep up with multiple fields at the same time. The ICU is not the OR and the OR is not the ICU, regardless of the skill set and knowledge set overlap. One of my biggest complaints regarding midlevels, especially NPs, is the non-sensical aspect of how they can jump from specialty to specialty. I know one NP that will cover for hospitalist shifts one day, ICU shifts a second, and ED shifts the third. Heck, the entire concept of acute care NP is pretty nonsensical as the aspects of treating inpatients, emergency patients, and critical care patients are all distinct things.... which is why EM doesn't do inpatient, IM doesn't (for the most part, and when they do it's often done poorly) EM, and for both to do critical care well, it's additional years of training.

 

[rdh218]

So this is a fair question... but one that has zero bearing on hours of experience.


Now I'm not a surgeon, but I'm going to guess the answer to that question is "no." for a variety of reasons.

1. The same issue with any combined multispecialty training. For example, the anesthesiologists who dream of doing cases one day and ICU the next day or EM-CCM who wants to be in the ED one day and ICU the next day. If I'm scheduling people for the ICU and you're full time, then while I might want to accommodate a schedule request, I might not have the ability to do so. What happens if you're scheduled to both cover the ICU and run cases at the same time? It's not like you can up and leave to go to the bedside of a crashing ICU patient.

Now, sure, a surgeon can't up and leave the case either, but that's what normally their midlevel is doing while they're in the case as well as the ICU team.

2. The surgeon doesn't command the anesthesiologist. So what happens when what the surgeon wants to happen in the SICU conflicts with what the anesthesiologist wants to do in the OR?

3. Knowledge is a factor. There's only so much people can retain and when it comes to being an expert in a field, it can be hard to keep up with multiple fields at the same time. The ICU is not the OR and the OR is not the ICU, regardless of the skill set and knowledge set overlap. One of my biggest complaints regarding midlevels, especially NPs, is the non-sensical aspect of how they can jump from specialty to specialty. I know one NP that will cover for hospitalist shifts one day, ICU shifts a second, and ED shifts the third. Heck, the entire concept of acute care NP is pretty nonsensical as the aspects of treating inpatients, emergency patients, and critical care patients are all distinct things.... which is why EM doesn't do inpatient, IM doesn't (for the most part, and when they do it's often done poorly) EM, and for both to do critical care well, it's additional years of training.

The clinical hours and experiences in my pervious post are relevant when comparing myself to another mid-level. The minimum requirement for an NP to graduate is a laughable 500 hrs and CRNA is only 1000. So what I'm saying is that I should clearly be more prepared clinically than most anyone applying for the same positions as me. I agree there are logistical challenges that would play a role in the feasibility of this type of position. I also agree knowledge is key and the settings are very similar but still very different in terms of management. It just seems like there has to be some benefit to understanding the short-term goals of the OR and the long-term goals of the ICU and having the capacity to implement a plan of care that makes sense for both versus the fragmented care that often happens between the two.

 

[chessknt]

The clinical hours and experiences in my pervious post are relevant when comparing myself to another mid-level. The minimum requirement for an NP to graduate is a laughable 500 hrs and CRNA is only 1000. So what I'm saying is that I should clearly be more prepared clinically than most anyone applying for the same positions as me. I agree there are logistical challenges that would play a role in the feasibility of this type of position. I also agree knowledge is key and the settings are very similar but still very different in terms of management. It just seems like there has to be some benefit to understanding the short-term goals of the OR and the long-term goals of the ICU and having the capacity to implement a plan of care that makes sense for both versus the fragmented care that often happens between the two.

The answer is still no, nobody sees any value in that. You might but the community at large doesn't. As a CCM attending I personally would see no value in it except that I would be worried that you would be overconfident of your ability to manage a vent because you are assuming the ICU vent practices are the same as the OR. The only scenario where this could ever work is if you can find an academic center where anesthesia runs the ICU and likes midlevels a lot in both departments.

 

[rdh218]

The answer is still no, nobody sees any value in that. You might but the community at large doesn't. As a CCM attending I personally would see no value in it except that I would be worried that you would be overconfident of your ability to manage a vent because you are assuming the ICU vent practices are the same as the OR. The only scenario where this could ever work is if you can find an academic center where anesthesia runs the ICU and likes midlevels a lot in both departments.

It doesn't take a medical degree to appreciate the differences in management between the OR and ICU, but I think most would agree there is a fair degree of overlap. Assuming someone couldn't differentiate vent management strategies between the OR and ICU is a bit of a reach, especially if they've received some degree of training in both. I can't say I've seen higher tidal volumes and or rates in an effort to drive down CO2 to suppress someone's innate drive for spontaneous respiration in the ICU, so it's relatively simple to conclude that I shouldn't do that outside of the OR. I think your assessment of where this type of role could work is probably fair. I don't anticipate that it would be widely accepted. What I do find odd in the feedback is that the additional education is perceived as a bad thing. Finding absolutely no value in the skillset at all, actually believing it to be concerning or dangerous, seems odd. How I interpret that is if my resume and that of another entry-level APP found their way to your desk, you would see no benefit in my having managed a large number of airways, my having a rudimentary understanding of vent management practices, having probably more experience with most of the medications, and having more experience with critical disease management. You would actually be more worried about any degree of confidence I may have in my abilities because of my background, and less worried about someone who probably graduated from whatever online degree mill, whose buddy signed off on their clinical hours, and has less than half of the same experience?

 

[chessknt]

It doesn't take a medical degree to appreciate the differences in management between the OR and ICU, but I think most would agree there is a fair degree of overlap. Assuming someone couldn't differentiate vent management strategies between the OR and ICU is a bit of a reach, especially if they've received some degree of training in both. I can't say I've seen higher tidal volumes and or rates in an effort to drive down CO2 to suppress someone's innate drive for spontaneous respiration in the ICU, so it's relatively simple to conclude that I shouldn't do that outside of the OR. I think your assessment of where this type of role could work is probably fair. I don't anticipate that it would be widely accepted. What I do find odd in the feedback is that the additional education is perceived as a bad thing. Finding absolutely no value in the skillset at all, actually believing it to be concerning or dangerous, seems odd. How I interpret that is if my resume and that of another entry-level APP found their way to your desk, you would see no benefit in my having managed a large number of airways, my having a rudimentary understanding of vent management practices, having probably more experience with most of the medications, and having more experience with critical disease management. You would actually be more worried about any degree of confidence I may have in my abilities because of my background, and less worried about someone with less experience, who probably graduated from whatever online degree mill, whose buddy signed off on their clinical hours, and has less than half of the same experience?

The fact that you don't understand that perspective is part of the problem. Physicians specialize in a single field. We spend a long time learning that field. We all go through a phase where we think we have a great idea of what is going on Dunning Krueger style then we see how stupid we were in retrospect after we learn more.. This gives us appreciation for what we don't know and a respect for expertise in other fields. When I had my first 50ish transbronchial biopsies down I felt like it was pretty easy until I had a massive airway bleed that nearly coded and died and had to get rescued by the IP attending who knew how to stop the bleed. Now I have dealt with my own major airway bleeds on my own because I have seen it a few times and am always prepared even though it is usually not needed, It is easier to teach someone who doesnt have this high degree of perceived competence.

As an example--Your 'management' of airways doesnt translate to ICU unless your attendings are having you do crashing COVIDs with sats in the 50s peri-coding throwing up blood with nobody else managing the induction or hemodynamics except you. Doing stable ASA 1-3s with excellent preoxygenation applies to very few ICU airways. My name is on your charts--if you think you are fine and don't need help and are wrong I get burned, not you. That is why we are so paranoid. If it was all on you with your license and financial future on the line for your decisions then I think you could have at it.

 

[rdh218]

The fact that you don't understand that perspective is part of the problem. Physicians specialize in a single field. We spend a long time learning that field. We all go through a phase where we think we have a great idea of what is going on Dunning Krueger style then we see how stupid we were in retrospect after we learn more.. This gives us appreciation for what we don't know and a respect for expertise in other fields. When I had my first 50ish transbronchial biopsies down I felt like it was pretty easy until I had a massive airway bleed that nearly coded and died and had to get rescued by the IP attending who knew how to stop the bleed. Now I have dealt with my own major airway bleeds on my own because I have seen it a few times and am always prepared even though it is usually not needed, It is easier to teach someone who doesnt have this high degree of perceived competence.

As an example--Your 'management' of airways doesnt translate to ICU unless your attendings are having you do crashing COVIDs with sats in the 50s peri-coding throwing up blood with nobody else managing the induction or hemodynamics except you. Doing stable ASA 1-3s with excellent preoxygenation applies to very few ICU airways. My name is on your charts--if you think you are fine and don't need help and are wrong I get burned, not you. That is why we are so paranoid. If it was all on you with your license and financial future on the line for your decisions then I think you could have at it.

Your response seems to assume that I'm asking for a high degree of independence and would want to function in some type of role that tries to replace physician involvement, and that's not the case. The idea of an inpatient mid-level should be intended to mitigate the physician workload, not replace them in a patients care. I would contend that most decisions should warrant some degree of discussion either prior to implementation or quickly following, because like you said, your name is on the chart. My perception of what the role should be, versus what other people with similar credentials try and fight for it to be, are different. I'm not looking for complete autonomy because my knowledge base doesn't justify that. My role should make it easier for physicians to see and manage 30+ patients if they work in a high-volume facility. I should be able to make safe decisions to temporize critical situations until the physician is available to either agree and continue that course of care or provide a more definitive solution. The role shouldn't try to replace physician judgment and evaluation in a patient's care. I'm not asking to be in the driver seat, I'm just asking to be in the car.

 

[chessknt]

Your response seems to assume that I'm asking for a high degree of independence and would want to function in some type of role that tries to replace physician involvement, and that's not the case. The idea of an inpatient mid-level should be intended to mitigate the physician workload, not replace them in a patients care. I would contend that most decisions should warrant some degree of discussion either prior to implementation or quickly following, because like you said, your name is on the chart. My perception of what the role should be, versus what other people with similar credentials try and fight for it to be, are different. I'm not looking for complete autonomy because my knowledge base doesn't justify that. My role should make it easier for physicians to see and manage 30+ patients if they work in a high-volume facility. I should be able to make safe decisions to temporize critical situations until the physician is available to either agree and continue that course of care or provide a more definitive solution. The role shouldn't try to replace physician judgment and evaluation in a patient's care. I'm not asking to be in the driver seat, I'm just asking to be in the car.

They need to hire another physician, not an np in that facility.

As above good luck trying to find what you are looking for.

 

[vector2]

This entire discussion is moot because CRNAs, especially if they're willing to travel/move, are currently making 3x what any ACNP is making. Everyone says they're not about the money while they're still in training, but the tune is always, always different once they start seeing that paystub.

 

[SurfingDoctor]

I just can’t understand why an institution would need a single advanced practitioner to cover two different locations in the hospital. I guess if they were short staffed but it would only be temporary probably.

 

[lunaire]

Your response seems to assume that I'm asking for a high degree of independence and would want to function in some type of role that tries to replace physician involvement, and that's not the case. The idea of an inpatient mid-level should be intended to mitigate the physician workload, not replace them in a patients care. I would contend that most decisions should warrant some degree of discussion either prior to implementation or quickly following, because like you said, your name is on the chart. My perception of what the role should be, versus what other people with similar credentials try and fight for it to be, are different. I'm not looking for complete autonomy because my knowledge base doesn't justify that. My role should make it easier for physicians to see and manage 30+ patients if they work in a high-volume facility. I should be able to make safe decisions to temporize critical situations until the physician is available to either agree and continue that course of care or provide a more definitive solution. The role shouldn't try to replace physician judgment and evaluation in a patient's care. I'm not asking to be in the driver seat, I'm just asking to be in the car.

The issue is that for CCM, NPs are being used to overextend the critical care service line. This is also true for CRNAs, and other fields in general.

As you said, NPs should not be used to replace physicians. Different training, skillset, liability, etc. However, this is what we see in actual clinical practice. CCM optimal physician to patient ratio should be 1:14 or so. When census becomes 18, 22, 24, They hire an NP as a "physician extender," but from the physician's perspective, we still have a full plate of 14 patients, and now, the extra liability of covering an NP taking care of the extra patients.

To answer your original question, I'm sure some hospital/practice admin would find value in that proposition, depending on how low a salary you'll accept. A more practical answer would be make yourself a 1099 or locums, and get 2 different jobs with exposure to both setting.

 

[kidthor]

In anesthesia we have plenty of people who do OR stuff plus ICU or ICU/CT-Anesthesia or PICU. Those folks can have some challenge finding the right job because many employers want you to do one or the other. However, anesthesia departments who also own the critical care side often do staff physicians in both the OR and the ICU. Ultimately it makes for a stronger department with a bigger footprint and more influence in the hospital.

For OP with a sincere interest in doing both in a midlevel sense - I think it's entirely possible in one of those departments who staffs both the OR and ICU, but it'll be a challenge because it's a non-standard path.

 

[The kitchen sink]

I am a licensed ACNP, primarily educated in critical care, and a present CRNA student. My end goal is to find a position that would allow me to function in a mid-level anesthesia/critical care type role, with both ICU and OR responsibilities. What are the chances that anyone in the medical community would find value in this type of position?

Work full time as a CRNA and do per diem as a CC NP. You’ll earn a fat paycheck and make more than a lot of physicians. Some of my physicians colleagues may be salty, but it’s the truth. The system of medicine is beyond repair in America, so make as make money as you can, help as many people as you can, be nice, stay humble, learn from your superiors and lay low overall. Good luck.

 

[jwk]

You're comparing apples and oranges.

No, he's not. Do you not read your own association's propaganda re # of hours/years of training?

 

[jwk]

Your response seems to assume that I'm asking for a high degree of independence and would want to function in some type of role that tries to replace physician involvement, and that's not the case. The idea of an inpatient mid-level should be intended to mitigate the physician workload, not replace them in a patients care. I would contend that most decisions should warrant some degree of discussion either prior to implementation or quickly following, because like you said, your name is on the chart. My perception of what the role should be, versus what other people with similar credentials try and fight for it to be, are different. I'm not looking for complete autonomy because my knowledge base doesn't justify that. My role should make it easier for physicians to see and manage 30+ patients if they work in a high-volume facility. I should be able to make safe decisions to temporize critical situations until the physician is available to either agree and continue that course of care or provide a more definitive solution. The role shouldn't try to replace physician judgment and evaluation in a patient's care. I'm not asking to be in the driver seat, I'm just asking to be in the car.

And again - you're totally ignoring your own association's propaganda about independent practice. That's SRNA 101. Independent practice and autonomy engulfs SRNAs from Day 1. You know it, I know it. We're perfectly OK hiring CRNAs in our practice, as long as they play by our anesthesia care team rules. Guess what? We can't find them, because they don't want to be working under an anesthesiologist's direction. They want to be independent an autonomous, just like their association and their educational programs say they should be.

 

[rdh218]

And again - you're totally ignoring your own association's propaganda about independent practice. That's SRNA 101. Independent practice and autonomy engulfs SRNAs from Day 1. You know it, I know it. We're perfectly OK hiring CRNAs in our practice, as long as they play by our anesthesia care team rules. Guess what? We can't find them, because they don't want to be working under an anesthesiologist's direction. They want to be independent an autonomous, just like their association and their educational programs say they should be.

So because I identify with a particular group, I'm not allowed to have differing opinions/beliefs from the majority? That's a fairly narrow-minded statement.

 

[turkeyjerky]

OP is definitely a troll.

These militant midlevels play this ish all the time. They come on here, w/ an initial, seemingly reasonable, post and then gradually ratchet up the rhetoric. Before you know it, they're posting snarky replies filled with obnoxious emojis and then "signing off" before coming back for more.

 

[chocomorsel]

You're comparing apples and oranges. You are assuming I am somehow equating anything I've done to that of a physician, and I'm not. I have no misunderstanding of how my education and clinical time compares to a medical education. My question regarding what I want to do is would physicians see any clinical utility in having someone with both skillsets? Would surgical specialties see any value in someone who could provide anesthesia for their cases and also help with post-operative ICU management? I'm not asking if physicians hate the idea of mid-levels because I know that answer without asking. I'm asking, in a system that is going to utilize mid-levels in anesthesia and critical care roles regardless, would there be any benefit to being able to "function" in both roles?

I am an intensivist and an anesthesiologist. I practice CCM full time. Often times you have to pick one or the other unless you are a physician in academics. I haven’t seen a midlevel practice both in the same hospital. I do have a friend that is both a PA and an AA and I can ask how he does. I trained w him in the OR.
Now considering CRNAs can work 3 days a week and be considered full time you can certainly work two jobs as many do, but in your case do two roles.

EDIT: No he never worked both in the same department.

 

[mudderMD]

I am a licensed ACNP, primarily educated in critical care, and a present CRNA student. My end goal is to find a position that would allow me to function in a mid-level anesthesia/critical care type role, with both ICU and OR responsibilities. What are the chances that anyone in the medical community would find value in this type of position?

Sounds like you want Anesthesia-CCM. Go to medical school.

 

[jwk]

I am an intensivist and an anesthesiologist. I practice CCM full time. Often times you have to pick one or the other unless you are a physician in academics. I haven’t seen a midlevel practice both in the same hospital. I do have a friend that is both a PA and an AA and I can ask how he does. I trained w him in the OR.
Now considering CRNAs can work 3 days a week and be considered full time you can certainly work two jobs as many do, but in your case do two roles.

EDIT: No he never worked both in the same department.

Smart guy (I wouldn't be surprised if I know him )

 

[chocomorsel]

Smart guy (I wouldn't be surprised if I know him )

Yea you probably do. He was in your neck of the woods.

 

[OptionOffense]

Sounds like you want Anesthesia-CCM. Go to medical school.

Why go to medical school when you can go to NP school online to achieve the same results?