Jets Opinion On Crnas Doing Pain Management

[jetproppilot]

As you all know, I am not anti_CRNA.

Quite the contrary.

I'm convinced the team-model is the best way to go. Argue at will at my opinion, but lets keep that for another thread.

But CRNAs getting the OK to do pain management?

That is REALLY absurd.

Really.

I mean, AANA, gimme a fu kk ing break.

I am more deft than most MDs out there.

Not bragging. Just stating da fact, and setting da stage.

Which certainly means I've got ALL CRNAs covered in knowledge/hand skills.

The CRNA lobbying group wants to make it OK for nurses to do pain management??????

I am board certified. I've got 11 years experience in the busy private practice realm.

I wouldnt even consider marketing myself as a pain guy, at least as my knowledge/hand-skills-at-all-pain-management-techniques sits at the moment.

If I did that I'd be lying to the patients about the product they'd receive, and lying to myself about my own ability.

SO, for an organization (AANA) to move in a direction to legally enforce their ability to work at a profession (pain management) that they are in no way qualified to perform, is no-less-than terrifying.

That move really pisses me off.

I'm glad they lost.

Otherwise I'd have to go egg the AANA building. And pee-pee on their cars.

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[Noyac]

crna's practicing pain management reminds me of a statement I read recently,"Part of being a highly trained specialist is knowing enough to acknowledge ambiguity- something novices frequently do not admit."

I think that says it all.

 

[Planktonmd]

As you all know, I am not anti_CRNA.

Quite the contrary.

I'm convinced the team-model is the best way to go. Argue at will at my opinion, but lets keep that for another thread.

But CRNAs getting the OK to do pain management?

That is REALLY absurd.

Really.

I mean, AANA, gimme a fu kk ing break.

I am more deft than most MDs out there, thank you very much.

Not bragging. Just stating da fact, and setting da stage.

Which certainly means I've got ALL CRNAs covered in knowledge/hand skills.

The CRNA lobbying group wants to make it OK for nurses to do pain management??????

I am board certified. I've got 11 years experience in the busy private practice realm.

I wouldnt even consider marketing myself as a pain guy, at least as my knowledge/hand-skills-at-all-pain-management-techniques sits at the moment.

SO, for an organization (AANA) to move in a direction to legally enforce their ability to work at a profession (pain management) that they are in no way qualified to perform, is no-less-than terrifying.

That move really pisses me off.

I'm glad they lost.

Otherwise I'd have to go egg the AANA building.

Great post as usual

As you know when it comes to politics and the legal system the truth is a very relative concept, It's actually very similar to military logic: The conqueror decides what the truth is.
So, it really doesn't matter if an idea makes sense or not, all that matters is who supports that idea and how much power they posses.

 

[BlackScorpion]

CRNAs doing pain management, with the AANA support.

Damn, how greedy can these nurses get.

 

[dhb]

Damn, how greedy can these nurses get.

At least as much as the MD's that train them

 

[SleepIsGood]

yes exactly....

If CRNAs werent trained/hired then they wouldnt be able to do pain mgt.



As the old adage goes, "give them a little, they'll want a lot".

 

[jetproppilot]

crna's practicing pain management reminds me of a statement I read recently,"Part of being a highly trained specialist is knowing enough to acknowledge ambiguity- something novices frequently do not admit."

I think that says it all.

Well said.

I'll plagiarize (not spelled right I'm sure) some dudes comment:

"THE HARDEST THING TO KNOW IS WHAT YOU DON'T KNOW."

 

[rmh149]

Well said.

I'll plagiarize (not spelled right I'm sure) some dudes comment:

"THE HARDEST THING TO KNOW IS WHAT YOU DON'T KNOW."

A college friend of mine that is a professor at UNT in the criminal justice department said:

When you finish your Bachelor degree: You feel you know all there is to know.

When you finish your Master degree: You realize there is much to learn.

When you finish your doctorate degree: You realize you know nothing.

I keep this in the back of my head and never regret telling someone..... "I dont know".

 

[dhb]

A college friend of mine that is a professor at UNT in the criminal justice department said:

When you finish your Bachelor degree: You feel you know all there is to know.

When you finish your Master degree: You realize there is much to learn.

When you finish your doctorate degree: You realize you know nothing.

And when you finish your DNP you're the master of the universe?...

 

[johankriek]

A college friend of mine that is a professor at UNT in the criminal justice department said:

When you finish your Bachelor degree: You feel you know all there is to know.

When you finish your Master degree: You realize there is much to learn.

When you finish your doctorate degree: You realize you know nothing.

I keep this in the back of my head and never regret telling someone..... "I dont know".

your mere existence in this world nauseates me.

 

[FirstAid]

Just wondering if these CRNAs who want to practice pain management are actually considering doing some of the more "surgical procedures." Like Jet, I'm not anti-CRNA, but I'm having a hard time picturing a CRNA performing a spinal cord stimulator implant, intrathecal pump implant, radiofrequency nerve ablation, and vertebroplasty/kyphoplasty. In a way, that's kind of like letting a nurse practitioner or physician assistant perform a lap chole or lap appy. Am I crazy in thinking that there is NO WAY that CRNAs can turf-in on these type of procedures? Afterall, these are basically surgical procedures requiring an understanding of surgical and medical management (which most, if not all, MDs have training in after residency) as well as at least a 1 year fellowship in interventional pain management.

Again, I'm not anti-CRNA, but I think it would be quite difficult for CRNA's to eventually be allowed to perform these surgical procedures in their "practice" of interventional pain medicine. Any thoughts?

 

[Stimulate]

No primary care doctor or surgeon with any common sense would even think about referring their patients to a CRNA. I will vigorously support the efforts to fight their entrance into pain management, however, I am confident in my ability to compete for referrals, etc. They can't write prescriptions, perform surgery, nor can they admit patients to hospitals so how "comprehensive" can their care be? Not to mention the growing trend towards requiring board certification for reimbursement for pain procedures...

 

[BLADEMDA]

Just wondering if these CRNAs who want to practice pain management are actually considering doing some of the more "surgical procedures." Like Jet, I'm not anti-CRNA, but I'm having a hard time picturing a CRNA performing a spinal cord stimulator implant, intrathecal pump implant, radiofrequency nerve ablation, and vertebroplasty/kyphoplasty. In a way, that's kind of like letting a nurse practitioner or physician assistant perform a lap chole or lap appy. Am I crazy in thinking that there is NO WAY that CRNAs can turf-in on these type of procedures? Afterall, these are basically surgical procedures requiring an understanding of surgical and medical management (which most, if not all, MDs have training in after residency) as well as at least a 1 year fellowship in interventional pain management.

Again, I'm not anti-CRNA, but I think it would be quite difficult for CRNA's to eventually be allowed to perform these surgical procedures in their "practice" of interventional pain medicine. Any thoughts?

So, you think that after getting a DNAP in "Anesthesia" and doing a 6 month fellowship in Pain Management a CRNA could never practice Pain?

Sorry, but the history of the AANA and the BON's don't agree with that statement. Once the Nursing Schools and Universities offer a Nurse Anesthetist Pain Management Fellowship you will see CRNA's enter this field.
I expect an "exam" by the AANA certifying the CRNA as a Pain Specialist. Then, CMS will reimburse Nurse Anesthetists. How long until the private payers are FORCED to follow suite?

The DNAP is the beginning of the AANA's full assault on the profession-not the end.

Blade

 

[Disciple]

Just wondering if these CRNAs who want to practice pain management are actually considering doing some of the more "surgical procedures." Like Jet, I'm not anti-CRNA, but I'm having a hard time picturing a CRNA performing a spinal cord stimulator implant, intrathecal pump implant, radiofrequency nerve ablation, and vertebroplasty/kyphoplasty. In a way, that's kind of like letting a nurse practitioner or physician assistant perform a lap chole or lap appy. Am I crazy in thinking that there is NO WAY that CRNAs can turf-in on these type of procedures? Afterall, these are basically surgical procedures requiring an understanding of surgical and medical management (which most, if not all, MDs have training in after residency) as well as at least a 1 year fellowship in interventional pain management.

Again, I'm not anti-CRNA, but I think it would be quite difficult for CRNA's to eventually be allowed to perform these surgical procedures in their "practice" of interventional pain medicine. Any thoughts?

Check "Cottage Hospital" in New Hampshire. I believe they're putting in stims there.

CRNAs have there own Interventional Pain Society Called "NAPES" which holds cadaver courses for CRNAs.

The good news is that the vast majority of interventional pain docs oppose CRNAs doing interventional pain procedures, and will fight against it tooth and nail.

 

[rmh149]

So, you think that after getting a DNAP in "Anesthesia" and doing a 6 month fellowship in Pain Management a CRNA could never practice Pain?

Sorry, but the history of the AANA and the BON's don't agree with that statement. Once the Nursing Schools and Universities offer a Nurse Anesthetist Pain Management Fellowship you will see CRNA's enter this field.
I expect an "exam" by the AANA certifying the CRNA as a Pain Specialist. Then, CMS will reimburse Nurse Anesthetists. How long until the private payers are FORCED to follow suite?

The DNAP is the beginning of the AANA's full assault on the profession-not the end.

Blade

I agree....I can see this happening. I don't necessarily agree with the push for CRNA's practicing pain management....my opinion. I like being at the head of the bed next to the anesthesia machine. But I guess some are trying to dip into that field. Who knows what doctorate level education in anesthesia for CRNA's will bring....we will se over the next 20 years or so.

 

[Disciple]

So, you think that after getting a DNAP in "Anesthesia" and doing a 6 month fellowship in Pain Management a CRNA could never practice Pain?

Sorry, but the history of the AANA and the BON's don't agree with that statement. Once the Nursing Schools and Universities offer a Nurse Anesthetist Pain Management Fellowship you will see CRNA's enter this field.
I expect an "exam" by the AANA certifying the CRNA as a Pain Specialist. Then, CMS will reimburse Nurse Anesthetists. How long until the private payers are FORCED to follow suite?

The DNAP is the beginning of the AANA's full assault on the profession-not the end.

Blade

I don't know. There's not really a "need" for more people who can do ESIs. Most interventional pain procedures are not backed by RCTs or even Class II evidence in many cases.

Utilization of pain procedures has increased dramatically every year since 2000. Medicare and insurers have already taken note and have cut reimbursement for basic injections and simply will not cover newer procedures i.e. Nucleoplasty, IDET, etc.

I'm skeptical that they would readily welcome a group of non-physicians looking to run up the bills. Private insurers have already set up their own policies to stop physicians from performing mass procedures without doing the proper conservative medical
management. How is a CRNA pain practicioner ever going to get any procedures authorized?

 

[BLADEMDA]

I don't know. There's not really a "need" for more people who can do ESIs. Most interventional pain procedures are not backed by RCTs or even Class II evidence in many cases.

Utilization of pain procedures has increased dramatically every year since 2000. Medicare and insurers have already taken note and have cut reimbursement for basic injections and simply will not cover newer procedures i.e. Nucleoplasty, IDET, etc.

I'm skeptical that they would readily welcome a group of non-physicians looking to run up the bills. Private insurers have already set up their own policies to stop physicians from performing mass procedures without doing the proper conservative medical
management. How is a CRNA pain practicioner ever going to get any procedures authorized?

You fail to recognize the role a CRNA can play in a Multi-modal pain practice.
While you think the American Academy of Pain Medicine isn't real I know for a fact Hospitals and Insurers recognize it. Thus, any Physician who passes this "exam" can hire a CRNA to work for him/her or along side him/her. This means Physicians who were not involvled with procedues will now be.

By working with a NueroSurgeon, Orthopedist, Physiatrist, etc. the CRNA pain specialist will have NO problems getting referals and authorization. Your refering Doctors will CUT YOU OUT of the equation by hiring the CRNA Pain Specialist to do the actual procedure.

Blade

 

[FirstAid]

So, if CRNAs get their way in interventional pain medicine, then they will essentially be able to perform surgery (spinal cord stims, intrathecal pumps, IDET, etc.)

Thus, doctors (orthos, neuros, FPs) will be willing to refer their patients to CRNAs for surgical pain procedures?

Whether they have a doctorate as a nurse practitioner or not, this is really hard to believe.

Would you refer your patients for a surgical procedure to be performed by a CRNA?

Again, I'm not anti-CRNA and find them very helpful in administering anesthesia. But, performing surgery and managing intra-op/post-op complications? Hmmmm....I think not.

Otherwise, NPs and PAs should be well qualified after a few months of "fellowship training" to perform appendectomies and fem-pop by-passes.

 

[rmh149]

So, if CRNAs get their way in interventional pain medicine, then they will essentially be able to perform surgery (spinal cord stims, intrathecal pumps, IDET, etc.)

Thus, doctors (orthos, neuros, FPs) will be willing to refer their patients to CRNAs for surgical pain procedures?

Whether they have a doctorate as a nurse practitioner or not, this is really hard to believe.

Would you refer your patients for a surgical procedure to be performed by a CRNA?

Again, I'm not anti-CRNA and find them very helpful in administering anesthesia. But, performing surgery and managing intra-op/post-op complications? Hmmmm....I think not.

Otherwise, NPs and PAs should be well qualified after a few months of "fellowship training" to perform appendectomies and fem-pop by-passes.

Blade, nice. You are giving me some pretty good ideas. Hmmmm, I might have to go into pain management. AGAIN, just kidding. I'm not interested. But I can see how the above could happen.

First Aid....I think if the CRNA is working with a NueroSurgeon, Orthopedist, etc. (as Blade said), the referals from other physicians would be going to the CRNA working with a doctor. The trust would be with the Doctor/CRNA team. I am sure the CRNA would have also gained credibility with the DR's in that area as well. With with good performance and outcomes the referals will come . In the end everyone invloved wins.

 

[FirstAid]

Hi, rmh149. Interventional pain management is one of many possible career choices that I'm considering after residency. I have seen CRNAs in action, and a lot of them are EXCELLENT in providing anesthesia in the general ORs. I have also seen CRNAs that are superb in placing spinals and epidurals on the OB floors. With this in mind, there may be a role that CRNAs can play in pain clinics by possibly administering epidurals under the guidance of a physician. Overall, you guys have my utmost respect.

But, I still believe that performing "surgery" may be over-extending the boundaries of CRNAs. Pure independent practice of CRNAs administering anesthesia in the general ORs is considered "practicing medicine." If CRNAs get an independent role in interventional pain management, you will essentially be "practicing surgery" as well (specifically if CRNAs decide to incorporate spinal cord stims, intrathecal pums, IDET, etc.)

Whether its under the guidance of a physician or not, do you believe that performing surgery is in the realm of practice of a CRNA?


Thanks in advance for your response. I'm just curious to see a CRNAs perspective on this.

 

[rmh149]

But, I still believe that performing "surgery" may be over-extending the boundaries of CRNAs. Pure independent practice of CRNAs administering anesthesia in the general ORs is considered "practicing medicine." If CRNAs get an independent role in interventional pain management, you will essentially be "practicing surgery" as well (specifically if CRNAs decide to incorporate spinal cord stims, intrathecal pums, IDET, etc.)

Whether its under the guidance of a physician or not, do you believe that performing surgery is in the realm of practice of a CRNA?

Good question. I can say that it is not within my realm of practice. I have no clue about pain management with the exception of epidural steroid injections. I have always thought CRNA's had nothing to do with pain management or even dreamed of practicing independently in their own clinic....until I read about it while participating in this forum. Yes, I was surprised to see what some are pushing for.

My first impression is no, CRNA's could never be in a position to perform surgical procedures. However, CRNA's are very ambitious creatures. If we can get someone to teach us by way of a residency or fellowship and gain the publics trust, I guarantee you some of us will jump on the opportunity. Especially if there is money involved.

Would it we be practicing medicine? I have no idea what it would be called. Honestly, I am surprised at the things we can do independently now. I wouldn’t put it passed the few CRNA's that can pull it off....with public support.

That being said, never forget...MD/DO's have more public trust than nurses. The word "nurse" itself has a very limiting definition in the eyes of the patient. I think it would be very difficult for a CRNA to compete with physicians for business. Think about it...unless you were a complete ***** as a doctor to deal with, who are other doctors going to refer their patients to. Unless a CRNA is the only pain management specialist available, I think a doctor would refer their patients to another doctor first. The CRNA would have to work triple overtime to gain the trust of referring physicians to get any business, if any at all, regardless of his/her capabilities. Now, adding the doctorate education (DNAP) into the mix may change things.....a little.

In short, I think physicians will always dominate and control the pain management field. Besides, CRNA's should focus on producing more CRNA's to staff the OR's. There are not enough of us to think about branching to another field.

Keep in mind. This is strictly my humble opinion...and a very limited one at that, considering I anticipate I will never practice PM.

 

[Planktonmd]

Well, when it comes to pain medicine, I can tell you that more than 50 % of chronic pain patients will gladly let anyone stick needles anywhere in their bodies, as long as someone is going to renew their narcotics prescription.
This is the fundamental theory behind running a successful pain practice.
So, if a procedure challenged physician who likes prescribing narcotics finds a CRNA who wants to stick needles in people they will make money.

 

[core0]

Well, when it comes to pain medicine, I can tell you that more than 50 % of chronic pain patients will gladly let anyone stick needles anywhere in their bodies, as long as someone is going to renew their narcotics prescription.
This is the fundamental theory behind running a successful pin practice.
So, if a procedure challenged physician who likes prescribing narcotics finds a CRNA who wants to stick needles in people they will maker money.

This is another fundamental difference in the AA/PA model. The PA takes over outside the OR. There are a fair amount of PA's doing pain medicine. Usually this lets the physician do more procedures while the PA does scrips and follow ups. There are a few PA's doing limited injections under physician supervision. Nobody doing stims or anything like that (I could confidently predict that will not pass any state BME).

David Carpenter, PA-C

 

[CremeSickle]

So what qualifies a PA to be doing in jections when we are here explaining why CRNAs (who do spinals, regionals and epidurals)?

Oh, i know what qualifies you, the ability for the MD to make more money while your doing it.

Sad.

My opinion for the record: CRNAs have no place in pain management. Neither do NP, PAs or any other midlevel anything.

 

[rmh149]

So what qualifies a PA to be doing in jections when we are here explaining why CRNAs (who do spinals, regionals and epidurals)?

Oh, i know what qualifies you, the ability for the MD to make more money while your doing it.

Sad.

My opinion for the record: CRNAs have no place in pain management. Neither do NP, PAs or any other midlevel anything.

I will have to say for now I 2nd that opinion....except under the supervision of the physician.

 

[core0]

So what qualifies a PA to be doing in jections when we are here explaining why CRNAs (who do spinals, regionals and epidurals)?

Oh, i know what qualifies you, the ability for the MD to make more money while your doing it.

Sad.

My opinion for the record: CRNAs have no place in pain management. Neither do NP, PAs or any other midlevel anything.

What qualifies the PA is the trust and experience of the physician to know they trained the PA to do things right. You act like making money is a bad thing.

And you speak from what experience? Also make sure your there for all the category II scrips so you can do that instead of spending time in the OR. I really don't exactly know what your position is. I know from your previous statement that you were a nurse that went to medical school. I know that you go to M&M so you must either be a resident, med student or hospital employee. I know what Jet and the others do. What gives you the expertise to make pronouncements like this?

David Carpenter, PA-C

 

[CremeSickle]

What qualifies the PA is the trust and experience of the physician to know they trained the PA to do things right.

So its OTJ training.

You act like making money is a bad thing.

It isnt. The majority complaint about CRNAs doing this sortof work (be it in conjunction with a physician or not) is that pain medicine can be highly dangerous and requires a higher level of training. I completely agree. A CRNA has, by far, more more education in relation to regional anesthesia and complications thereof than any PA or NP would yet i wouldn't want a CRNA doing pain medicine.

Making money is fine as long as patient safety isnt compromised.

What gives you the expertise to make pronouncements like this?

I am in my 3rd year of anesthesia residency. Ive seen on numerous occasions, many breeches in the 'safety' issue when it comes to PA/NPs and the attendings need to go golfing or spend time on the "money" procedures. This, to me, seems a similar issue.

 

[core0]

So its OTJ training.

Yes although there are a number of courses. The same ones that physicians take. Wether that is a good or bad thing I have no real comment.


It isnt. The majority complaint about CRNAs doing this sortof work (be it in conjunction with a physician or not) is that pain medicine can be highly dangerous and requires a higher level of training. I completely agree. A CRNA has, by far, more more education in relation to regional anesthesia and complications thereof than any PA or NP would yet i wouldn't want a CRNA doing pain medicine.

Making money is fine as long as patient safety isnt compromised.

The pricinple problem I have with a CRNA is that they are not trained in medicine. CRNA training as I understand it is focused around the perioperative environment. Obviously anesthesiology training is more expansive and gives a broader exposure to the general practice of medicine. CRNA's attempting to move outside the perioperative environment are moving outside their scope of practice. Just as an NP would be outside their scope of practice doing anesthesia.

Part of this is the difference between an independent license to practice nursing (where your scope is related soley to the didactic and clinical training that a CRNA or NP receives) and the dependent license to practice medicine (where the scope of practice is limited to what the supervising physician can do and what they allow the PA to do). Functionally in some states this limits the NP or CRNA scope to what they learned in school. On the other hand the physician can decide to expand the PA skill set. If the PA goes to work for another physician, the physician can decide to keep things the same or restrict that skill set.


I am in my 3rd year of anesthesia residency. Ive seen on numerous occasions, many breeches in the 'safety' issue when it comes to PA/NPs and the attendings need to go golfing or spend time on the "money" procedures. This, to me, seems a similar issue.

I'm sorry you have had such a poor experience with PA's and NP's. In most situations PA's and NP's provide high quality cost effective care. In our practice (GI) we definitely provide an opportunity for the physicians to do more "money" procedures. However we also provide faster patient access to specialty care and prompt access to inpatient care.

In private practice their is very little interaction between PA's and anesthesiology (in my market I have never encountered a CRNA). Mostly when I talk to an anesthesiologist it is to arrange anesthesia for a case. We have a good relationship and our physicians are happy to have them there.

In the realm of pain management we have quite a few PA's in pain management in the market. As I am sure you know there is a dearth of pain management in most private practice markets. The PA's in my market for the most part see some new patients but mostly do follow up. As far as procedures, I know that they are doing some, but it is my understanding that it is mosty office based procedures. As far as being dangerous I cannot really comment on the risk vs. other specialties. I would agree that the procedural part requires a higher level of training, but the other parts of a treatment protocol (narcs, atypicals etc.) are within the skillset of a PA to follow once they have designed the plan with their SP.

I would submit that your perception is a single institution that is probably not representative of what goes on in the rest of the world. Our physicians are happy that we are there not only for the extra income, but for the quality of life issues. Prior to our starting a weekend day would frequently end at 8-9pm. With PA's assisting with the inpatient rounding we get out at 4-5 pm despite a substantial increase in volume. I would not underestimate a quality of life impact.

David Carpenter, PA-C

 

[CremeSickle]

Good response David.

I better understand what you meant in reference to pain now. Not really what i was thinking.

 

[Noyac]

David, I wouldn't worry too much about arguing with some of the people here. Some are very concerned about their future. They see all midlevels as a threat. Its nothing personal.

I am curious though as to why PA is on this site?

 

[core0]

David, I wouldn't worry too much about arguing with some of the people here. Some are very concerned about their future. They see all midlevels as a threat. Its nothing personal.

I am curious though as to why PA is on this site?

I've been asked about supporting an AA program locally. Kind of interested about how the relationship between AA's and Anesthesiologists is. The whole CRNA v. Anesthesiologist thing is really the best entertainment on the board. I also am writing a paper on NPP educational models and this is an interesting perspective (although I really won't touch on CRNA's or AA's much).

From a PA perspective on the time and training committment the CRNA is most similar to the PA model (speaking of didactic and clinical hours). Also from my perspective I think the AA's are going through the same fight that we have gone through at times. We have the advantage of support of the whole AMA. There seems to be a schizoid decision process in supporting the CRNA and AA's from the ASA (which has been discussed at length). We are starting to see some of the same reaction here on the whole NP independence thing from the organized medical establishment. It is good to see what is working and what doesn't in a specialty.

Mostly I lurk, but I occasionally need to defend my chosen profession. I think that a lot of people misunderstand the role and relationship between a PA and physician. We need to do a better job of educating residents who may not be exposed to PA's. Like I have said previously I appreciate what you all do, just not really something I would like (my pseudo ADD does not go well with sitting for long periods of time). I worked in the OR prior to PA school and got to know some of the anesthesiologists really well (no CRNA's here).

David Carpenter, PA-C