Medical Students- Anesthesiology?

[johankriek]

I forgot to mention this in an earlier post--

Some have suggested that the rise of the CRNA, and more generally, the mid-level provider, is most attributable to the old guard of greedy anesthesiologists and physicians who simply wanted maximize case loads and profits. This is short-sighted and simplistic. It was not a desire to maximize profits that prompted the rise of mid-level providers--it was the desire to maintain them. Falling re-imbursements in the mid-1990s demanded that physicians increase workloads and workhours to maintain their current levels of profitability. A nurse practitioner was a logical solution. In addition, NPs became a logical solution to the manpower shortage that ensued after the institution of the ACGME work hour rules. Mid-levels in all fields of medicine have bridged gaps in coverage imposed by limiting resident work hours.

Whereas the initial proliferation of mid-levels was a result of the pressures discussed above, the subsequent proliferation is due to the realization that, in some instances, appropriately supervised mid-levels can provide equivalent care to physician-only care models--for example in outpatient family practice clinic. Repetition is key: an experienced NP diagnosed my wife's pityriasis rosea in three minutes (she sees this rash twice a month, I certainly did not recall at that time that a herald patch followed by a rash in a Christmas tree distribution was classic for the syndrome). Repetition is key: after years of practice, my father's NPs in his ER can just as adequetely diagnose atypical chest pain as GERD as he or I can (provided that my father reviews the history and ECG himself). Repetition is key (please appreciate my rhetorical pun): a CRNA doing lap chole's each day can provide just as safe an anesthetic as the majority of residents, if not attendings, can (provided there is supervision for the infrequent complication).

This is the crux of the issue, that it does not take a rocket scientist--or a family practitioner or an anesthesiologist or even a cardiothoracic surgeon--to diagnose a common rash, navigate a lap chole, or harvest a saphenous vein. It takes these highly qualified professionals to direct, manage, and, yes, rescue those mid-levels who have more appropriate (read: to their level of training) skill sets. This is the most important thing, not whether it is fair that "our turf" is being invaded by mid-levels.

(Please note that I am NOT advocating individual practice for CRNAs, though I realize that they are.)

I think YOU are being shortsighted.

ok You can show a LPN pictures of rashes for a whole month.. does that make them qualified to diagnose skin lesions.?? I guess accorging to your logic it is.. So why have NPS.. just show every one whoe wants to be a dermatologist a picture book and tell them to come back in 30 days and boom.. Dermatologist.. OR is it more complicated than that.. You think a lap chole is a lap chole huh.. how about acute cholangitis... how about elevated liver enzymes.. how about elevated wbc count/// how about obesity.. .. there are complicated things in every single case... CRNAS and NPS just dont know about it becuase they dont have the breadth of knowledge.. .. furthermore, the judgement that a physician has is invaluable to patient care.. You should be ashamed of yourself for posting what you posted if you are a physician.. If you are a mid level.. sigh... should I move to europe..

I dont get paid to rescue anything.. I get paid appropriately use my expertise so rescue is not necessary..

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[Duckie24]

I think I am probably feeling the same as a bunch of the other newbies who recently entered and are about to enter this field. We are completely aware of this pressing issue and would like to do what we can to help with the situation. We are also reading what others on this forum have to say and understand the ideas that are being brought. However, the thought that keeps nagging at me as I read and re-read the discussion is that the people with the ideas seem to be just dumping them and then doing their best to wash their hands with it at that point. I find that very frustrating. Of course I'd love to carry the torch, but no one who cares would show up to see me run the race. If you really believe that the mail boy raising a concern to the CEO is going to get the same attention as the senior VP, well, then you've come up with some great ideas but are completely naive. As one of the newbies, I am ready and willing to help out, but you more experienced folks need to carry that torch. And if you don't understand that and believe that as well then all these great ideas are completely wasted.

 

[urgewrx]

Duckie, you can contribute to the ASA political action committee. These other guys who like to post a lot of BS blaming the academic community are too cheap to contribute.
​

 

[toughlife]

I forgot to mention this in an earlier post--

Some have suggested that the rise of the CRNA, and more generally, the mid-level provider, is most attributable to the old guard of greedy anesthesiologists and physicians who simply wanted maximize case loads and profits. This is short-sighted and simplistic. It was not a desire to maximize profits that prompted the rise of mid-level providers--it was the desire to maintain them. Falling re-imbursements in the mid-1990s demanded that physicians increase workloads and workhours to maintain their current levels of profitability. A nurse practitioner was a logical solution. In addition, NPs became a logical solution to the manpower shortage that ensued after the institution of the ACGME work hour rules. Mid-levels in all fields of medicine have bridged gaps in coverage imposed by limiting resident work hours.

Whereas the initial proliferation of mid-levels was a result of the pressures discussed above, the subsequent proliferation is due to the realization that, in some instances, appropriately supervised mid-levels can provide equivalent care to physician-only care models--for example in outpatient family practice clinic. Repetition is key: an experienced NP diagnosed my wife's pityriasis rosea in three minutes (she sees this rash twice a month, I certainly did not recall at that time that a herald patch followed by a rash in a Christmas tree distribution was classic for the syndrome). Repetition is key: after years of practice, my father's NPs in his ER can just as adequetely diagnose atypical chest pain as GERD as he or I can (provided that my father reviews the history and ECG himself). Repetition is key (please appreciate my rhetorical pun): a CRNA doing lap chole's each day can provide just as safe an anesthetic as the majority of residents, if not attendings, can (provided there is supervision for the infrequent complication).

This is the crux of the issue, that it does not take a rocket scientist--or a family practitioner or an anesthesiologist or even a cardiothoracic surgeon--to diagnose a common rash, navigate a lap chole, or harvest a saphenous vein. It takes these highly qualified professionals to direct, manage, and, yes, rescue those mid-levels who have more appropriate (read: to their level of training) skill sets. This is the most important thing, not whether it is fair that "our turf" is being invaded by mid-levels.

(Please note that I am NOT advocating individual practice for CRNAs, though I realize that they are.)

Any third year medical student rotating through OB/Gyn could have told you what your wife's rash was. I used to see a lot of it in OB/GYn clinic.

 

[Bertelman]

my kid aint going to no NP at the peds clinic... PERIOD.. PAL...

nor is a crna putting my kid or any of my loved ones to sleep


how is that for decisions...

Great, but judging from your presence in this forum, I wouldn't consider you to be part of the "public" that needs to be informed.

I'm just trying to say it's the legislators that need to be convinced. I'm all for throwing up a few billboards, but I wouldn't gamble the future on educating the public in the hopes they will drive CRNAs out of the market. Truth be told, most of them don't care. They want to be asleep during the surgery, and they want to awaken after it ends.

When Joe Q Public presents for surgery, do you think they are asked if they would prefer a CRNA or anesthesiologist? Then I'm not sure how a mass public education blitz is the cornerstone to our cause.

 

[Robert Loblaw]

I think YOU are being shortsighted.

ok You can show a LPN pictures of rashes for a whole month.. does that make them qualified to diagnose skin lesions.?? I guess accorging to your logic it is.. So why have NPS.. just show every one whoe wants to be a dermatologist a picture book and tell them to come back in 30 days and boom.. Dermatologist.. OR is it more complicated than that.. You think a lap chole is a lap chole huh.. how about acute cholangitis... how about elevated liver enzymes.. how about elevated wbc count/// how about obesity.. .. there are complicated things in every single case... CRNAS and NPS just dont know about it becuase they dont have the breadth of knowledge.. .. furthermore, the judgement that a physician has is invaluable to patient care.. You should be ashamed of yourself for posting what you posted if you are a physician.. If you are a mid level.. sigh... should I move to europe..

I dont get paid to rescue anything.. I get paid appropriately use my expertise so rescue is not necessary..

Sir, with all due respect, I do not think that I said that mid-levels are equivalent to physicians. In fact, I was very careful to include a qualification, that it is imperative that mid-levels have professionals (such as yourself) overseeing their action. The mere fact that you differentiate ascending cholangitis suggests that you acknowledge that there exists a gradient of complexity with respect to cases, to which the appropriately trained care-provider should be matched (otherwise, why not just say that you should be the only provider for a lap chole, period).

I don't think I should be ashamed of myself as a physician for being candid with the appropriate role I should play in a hospital, and certainly not for trying to expand my role as a perioperative physician. Furthermore, the purpose of my post is to refocus the discussion on the appropriate question: whether mid-levels, WITH THE APPARENTLY DIFFICULT TO UNDERSTAND CAVEAT OF SUPERVISION, can provide effective care IN SOME INSTANCES. If the answer to this question is yes, which I, unfortunately, think IN SOME INSTANCES is, we are being dishonest with ourselves and our patients insisting that we MUST be the only provider of their anesthetic, and by this I mean physically in the room 100% of the time, even if 90% of that time is surfing the web on our PDAs.

 

[Robert Loblaw]

Any third year medical student rotating through OB/Gyn could have told you what your wife's rash was. I used to see a lot of it in OB/GYn clinic.

Respectfully, I cannot tell if you are agreeing with me and adding evidence to my argument, or diasgreeing with me, citing an example, and proving my point for me.

It is not the underlying knowledge of HHV-6 tissue tropism and pathophysiology that allows you to make that diagnoses--IT IS SEEING A LOT OF IT IN OB/GYN clinic!

And another thing, I would argue that an MS3 is more similar to an NP at this point in training than a physician. The average MS3, much like an NP, functions almost solely on pattern recognition that triggers management protocols. The supervisor, who, himself once an MS3, then modifies management based on the subtleties of the individual case...sound familiar? (JohannKreik, please note the proper use of ellipses here. It is your grammar of which you, as a physician, if you are one, should be ashamed...sound familiar?)

 

[Bertelman]

It is not the underlying knowledge of HHV-6 tissue tropism and pathophysiology that allows you to make that diagnoses--IT IS SEEING A LOT OF IT IN OB/GYN clinic!

Damn, now I want my tuition money refunded for one year of Pathophysiology lectures. AND that big-a$$ Robbins book!

 

[johankriek]

Sir, with all due respect, I do not think that I said that mid-levels are equivalent to physicians. In fact, I was very careful to include a qualification, that it is imperative that mid-levels have professionals (such as yourself) overseeing their action. The mere fact that you differentiate ascending cholangitis suggests that you acknowledge that there exists a gradient of complexity with respect to cases, to which the appropriately trained care-provider should be matched (otherwise, why not just say that you should be the only provider for a lap chole, period).

I don't think I should be ashamed of myself as a physician for being candid with the appropriate role I should play in a hospital, and certainly not for trying to expand my role as a perioperative physician. Furthermore, the purpose of my post is to refocus the discussion on the appropriate question: whether mid-levels, WITH THE APPARENTLY DIFFICULT TO UNDERSTAND CAVEAT OF SUPERVISION, can provide effective care IN SOME INSTANCES. If the answer to this question is yes, which I, unfortunately, think IN SOME INSTANCES is, we are being dishonest with ourselves and our patients insisting that we MUST be the only provider of their anesthetic, and by this I mean physically in the room 100% of the time, even if 90% of that time is surfing the web on our PDAs.

Sir, you are intimating that simple cases should be delegated to crnas while complex cases should be the realm of a physician. And Im adding that all cases are complex and it is diifficult to ferrett out which ones are truly straightforward (which i dont believe exists) and which ones are more complex. So to solve this dilemma in my mind.. physicians need to be involved in every single case that goes to the operating room. and trust me if you are a patient... you wont think your case is straightforward or minor.. no matter how minor everyone else thinks it is.. If this is cannot be achieved in the United States.. where it can in europe we have major major problems....

would you let a nurse practicioner put in a permacath in the operating room? or amputate a foot or toe..

 

[chicamedica]

Sir, you are intimating that simple cases should be delegated to crnas while complex cases should be the realm of a physician. And Im adding that all cases are complex and it is diifficult to ferrett out which ones are truly straightforward (which i dont believe exists) and which ones are more complex. So to solve this dilemma in my mind.. physicians need to be involved in every single case that goes to the operating room. and trust me if you are a patient... you wont think your case is straightforward or minor.. no matter how minor everyone else thinks it is.. If this is cannot be achieved in the United States.. where it can in europe we have major major problems....

would you let a nurse practicioner put in a permacath in the operating room? or amputate a foot or toe..

Agree 100%.


btw, is medicine turning back into a field that trains only by apprenticeship (as it was in the pioneer days, or in ancient greece), despite being much more complex with so much more having been discovered since? the midlevels functioning independently as diagnosticians and writing scripts is essentially heading that way. Absurd. Treating everything by protocol is a risky way to proceed. As someone mentioned there are always subtleties that need to be considered. One case of chest pain is not the same as another. One case of hernia repair may not be the same situation as another.

I've been seen by a NP in the past. In general med clinic, I had already diagnosed myself and knew what should be done, so I didn't care who saw me. In derm clinic, I felt cheated b/c i have a family history of melanoma and would doubt that the NP would be able to recognize a subtle lesion (and i had made the appt with the MD, and waited so freaking long for it!).

I agree that if people were asked to make the choice to be seen/managed by a physician vs solely an NP/CRNA/PA/other midlevel, they would choose the former (imo, with good reason). That said, with attending supervision, I do agree that midlevels are helpful in reducing resident work hours and helping us have some time for other academic pursuits. They largely function as interns (with much much better hours).

 

[Coastie]

lol, true that...


The thing our friend who said we learn in the clinic, not the books, doesn't realize that lives are saved in the library, not the ER/OR.

If you don't have the knowledge base, you're in trouble.

Damn, now I want my tuition money refunded for one year of Pathophysiology lectures. AND that big-a$$ Robbins book!

 

[Robert Loblaw]

lol, true that...


The thing our friend who said we learn in the clinic, not the books, doesn't realize that lives are saved in the library, not the ER/OR.

If you don't have the knowledge base, you're in trouble.

Please, let's be realistic and, at least, accurately represent my position. Go back and read my initial post--I am the one who is arguing that we need to expand our scope of practice (knowledge base) into perioperative medicine because it is more fit to our levels of intelligence and training. Good ER nurses can run a code better than 85% of the academic internal specialists at my institution. If you want to save lives in a library, you are going to have to bring a defibrillator and pitch a tent.

 

[Robert Loblaw]

Sir, you are intimating that simple cases should be delegated to crnas while complex cases should be the realm of a physician. And Im adding that all cases are complex and it is diifficult to ferrett out which ones are truly straightforward (which i dont believe exists) and which ones are more complex.

I'm not suggesting that CRNAs should have cases delegated without oversight. Try this, substitute first-year, first-month anesthesia resident for CRNA in your or my statements. We will suppose that this resident does not represent anyone in this forum )to prevent the flack that I'm sure will fly after I hit return...). The young resident comes up with a generic which he presents to an attending who then modifies it because of the subtleties involved.

 

[poster]

EtherMD

I guess I live in a hole because where I practice we have not really heard too much about this AA thing that keeps being mentioned and we are curious about it. How would you go about hiring an AA when all you have is CRNA's? I like this AA option and would like to hear more about it. I have read some of your posts and am convinced that you have researched this and have good knowledge of what might be on the horizon and we probably all need to look hard at AA's. I have heard on occasion some of the nurses in the ICU talking about getting their doctorate to go on to CRNA and jokingly making statements about being called doctors and I would just laugh but this all sheds new light on the subject. From my experience with the nurses we have not even a DNP would help them in being better anesthesia providers.

 

[poster]

EtherMD

I wouldn't worry about urgewrx too much. I may be new to posting but I have read a few of his/her postings and I am convinced that he/she is a
CRNA in disguise.

 

[Taurus]

EtherMD

I guess I live in a hole because where I practice we have not really heard too much about this AA thing that keeps being mentioned and we are curious about it. How would you go about hiring an AA when all you have is CRNA's? I like this AA option and would like to hear more about it. I have read some of your posts and am convinced that you have researched this and have good knowledge of what might be on the horizon and we probably all need to look hard at AA's. I have heard on occasion some of the nurses in the ICU talking about getting their doctorate to go on to CRNA and jokingly making statements about being called doctors and I would just laugh but this all sheds new light on the subject. From my experience with the nurses we have not even a DNP would help them in being better anesthesia providers.

This is what needs to happen more often. Practicing anesthesiologists need to be aware of what's happening to their profession. A first good step in turning the corner is opening more AA schools. 5 is just pitiful. Besides the nurses not liking it, what is disincentive for converting CRNA programs into AA ones? The argument can be made that by making them into AA programs you'll attract a wider applicant pool and even better students. The conversion costs should be minimal because the training is the same, right?

 

[poster]

Please, let's be realistic and, at least, accurately represent my position. Go back and read my initial post--I am the one who is arguing that we need to expand our scope of practice (knowledge base) into perioperative medicine because it is more fit to our levels of intelligence and training. Good ER nurses can run a code better than 85% of the academic internal specialists at my institution. If you want to save lives in a library, you are going to have to bring a defibrillator and pitch a tent.

I think you are making statements that hurt MD's. The reason why you may have nurses running code's better is because of ACLS. Nurses that run codes are doing so by an algorhythm that has been proven to save lives not because of something that they themselves have thought up. Get real. Maybe those internal meds. may have never taken ACLS. Given a recipe anyone with alot of practice can run codes well. I bet when it is a difficult code or someone doesn't respond according to ACLS you would wish that there was someone with knowledge they gained thru medical school, books, residency, etc.

 

[toughlife]

Everything is protocolized because in this country people like to have directions on how to do everything.

The reason why we got caught with our pants down on 9/11 was because we didn't have a protocol for that.

 

[johankriek]

I think you are making statements that hurt MD's. The reason why you may have nurses running code's better is because of ACLS. Nurses that run codes are doing so by an algorhythm that has been proven to save lives not because of something that they themselves have thought up. Get real. Maybe those internal meds. may have never taken ACLS. Given a recipe anyone with alot of practice can run codes well. I bet when it is a difficult code or someone doesn't respond according to ACLS you would wish that there was someone with knowledge they gained thru medical school, books, residency, etc.

what he is saying is complete and utter stupidity........

Internal medicine docs.. know that friggin algorhythm like the back of their hand.. thats all they do.. I dont care how long a nurse has been in the ER, they just dont got the training to run a code.. thats not waht they are trained to do.. and anyone who says that just dont know what theyre talking about or they just havent been around for any significant period of time.. maybe a med student or something.. wasnt robert a med student over the summer... see tats the problem.. many people very early in thier training are making comments about things they just dont know about. and thats where we have to gently correct them... I dont think he is a horrible person for saying that, he is just totally mis informed.. I am even wondering what he did during his internal medicine months

 

[johankriek]

Everything is protocolized because in this country people like to have directions on how to do everything.

The reason why we got caught with our pants down on 9/11 was because we didn't have a protocol for that.

I with you tough.. i am totally against any protocols... or algorhythm..

 

[johankriek]

EtherMD

I wouldn't worry about urgewrx too much. I may be new to posting but I have read a few of his/her postings and I am convinced that he/she is a
CRNA in disguise.

I think conflicted, uregewrx and eutopia crna are the same person NITECAP. one of them is definitely nitecap, maybe all three

 

[Robert Loblaw]

I think you are making statements that hurt MD's. The reason why you may have nurses running code's better is because of ACLS.

I understand what you are saying--I'm not happy about the facts, per se, I'm just trying to be honest about them, rather than circle the wagons and insist that WE are the only ones who can provide "protocolized" medicine. Physician research and expertise are critical in the development of protocols; their execution does not necessarily require the same level of expertise. I am just trying to promote a sober and realistic assessment of the role that physicians and mid-levels play in a hospital.

My point is this: if it is, in fact, true, that there are some instances in which appropriately supervised mid-levels can provide equivalent care, we as physicians will be unable to justify our providing those same services at increased expense. I believe that this is the same vein that EtherMD mines when he implores future graduates to broaden their areas of expertise, to protect their futures against the gradual encroachment of mid-levels, fueled in part by the realization that super-smart, super-specialized people (us) should be appropriately utilized in positions in which their super-smarts and super-specialization is most useful.

 

[eutopia CRNA]

Sure, but is it coming to the CRNA world?

I don't see all the existing CRNAs taking time off from their increasingly lucrative practice to go back to school. Even if the AANA wanted to make this pseudo-doctorate a requirement, they'd face a rebellion from the ranks of old, crotchety, lazy, happy-with-the-status-quo, I'm-good-enough-already members.

And where are all the future CRNAs going to get the education/training needed to turn their CRNA papers into something with d-o-c-t-o-r on it? If their seniors/teachers are CRNAs sans doctorate, who's going to teach them? Or is a DNP going to become a prerequisite for CRNA training? If so, won't that drastically reduce the number of students entering training?

I'm not one to stick my head in the sand over this, but I'm dubious. I don't see a plausible sequence of events that will result in even a pretend doctorate degree becoming commonplace amonst CRNAs ... let alone it happening "soon." But I'd like to hear your thoughts on how it might happen.

It's true, yes, we CRNA's to have the opportunity to receive doctorates in the field of anesthesia, making us Dr. Nurse. I am slated to become one of the first in Texas this next year. Texas Christian University is the first establishment in Texas to adopt this program and I'm on the list. I agree that a lot of the "old, crotchety, lazy" CRNA's may not want to extend themselves but as for the "young, happy, energetic" CRNA's like me out there....well, just try and stop us. As for staff, well, much of the teaching staff in CRNA programs are PhD's and MD's who also teach at the medical school level (bet you didn't know that). At least it was that way in my program. Anyway, these same fine people will be teaching the doctorate programs. How they will grandfather the old & crotchety, I don't know. I can tell you that it will be mandatory to have a doctorate in a few short years, just as the NP program will also become a doctorate. Yes, our salaries are CLIMBING like crazy, and I know it scares the daylights out of many of you. Rightfully so. You obviously have much more extensive training and your knowledge base is incredible. I look at myself as adjunct to the physician, not a replacement by any means. I know A LOT of CRNA's don't view it that way and think they are just as smart, clinically sound, etc. Just ain't so! (although there are a few SCARY anesthesiologists out there, and we've all met them). The moral of the story is.....great for us, not so great for ya'll. I really hate that too. It should be about team work not competition.

 

[Taurus]

Don't they have a law that says you need an MD/DO to be called "Doctor" in the clinical setting? Or is this a state-by-state thing?

 

[Robert Loblaw]

what he is saying is complete and utter stupidity........

Internal medicine docs.. know that friggin algorhythm like the back of their hand.. thats all they do.. I dont care how long a nurse has been in the ER, they just dont got the training to run a code.. thats not waht they are trained to do.. and anyone who says that just dont know what theyre talking about or they just havent been around for any significant period of time.. maybe a med student or something.. wasnt robert a med student over the summer... see tats the problem.. many people very early in thier training are making comments about things they just dont know about. and thats where we have to gently correct them... I dont think he is a horrible person for saying that, he is just totally mis informed.. I am even wondering what he did during his internal medicine months

Excluding cardiologists and pulmonologists, I have never seen a code run by IM residents, rheumatology attendings, or even internists with years of experience that was not, forgive my French, a huge cluster-f**k. Anesthesiologists run organized codes.

I will admit that, with more experience, my opinion on this matter may change; however, my apparent inexperience, alone, should not invalidate my ideas. Your being able to disprove them should. I do not think that you have shown that appropriately supervised (by physicians) mid-levels cannot provide equivalent care in some instances.

Your questioning my performance in my internal medicine rotation is baseless, not to mention completely unrelated to the discussion. I can assure you I did very well, with superlatives the most common adjectives in my evaluations. I can give you my SAT scores, MCATs, USMLE scores, IQ, and anything else you would like as well...

 

[eutopia CRNA]

I think YOU are being shortsighted.

ok You can show a LPN pictures of rashes for a whole month.. does that make them qualified to diagnose skin lesions.?? I guess accorging to your logic it is.. So why have NPS.. just show every one whoe wants to be a dermatologist a picture book and tell them to come back in 30 days and boom.. Dermatologist.. OR is it more complicated than that.. You think a lap chole is a lap chole huh.. how about acute cholangitis... how about elevated liver enzymes.. how about elevated wbc count/// how about obesity.. .. there are complicated things in every single case... CRNAS and NPS just dont know about it becuase they dont have the breadth of knowledge.. .. furthermore, the judgement that a physician has is invaluable to patient care.. You should be ashamed of yourself for posting what you posted if you are a physician.. If you are a mid level.. sigh... should I move to europe..

I dont get paid to rescue anything.. I get paid appropriately use my expertise so rescue is not necessary..

Sir, I think you sadly have a deep lack of knowledge regarding CRNA education. We are not just some lay person off the street who was shown pictures of an endotracheal tube and lung, and then told "just pass the gas through this tube". I know that there is difference between your education vs. ours, but please don't sumise that CRNA's are idiots. It seems that you place our intelligence somewhere between a primate and a feral child. How insulting. I would NEVER insult your intelligence or training. I have the deepest respect for physicians. Why can't you afford some level of respect and understanding for our profession? CRNA's are NOT the same as MD/DO's. If we were, we would be MD's or DO's. We are our own entity with our own level of expertise. I am really bored with the attitude of those threatened by our mere existence on this planet. I ask you, is this a TRUE concern about patient safety (which is proven, there is no increase with morbidity & mortality with CRNA vs. MD), or is it more a financial threat that has you in such a dander? Yes, we are less expensive and yes, we cut money out of your pocket. I understand how that must sting.....But it doesn't mean we are bad people. Some respect would be nice. Kudos to all the docs out there who have treated us as part of the team and don't feel threatened by us! There are so many of you and you are fabulous!

 

[poster]

I understand the point you are making. I believe that midlevels are quite capable and are a necessary part of the overall picture as other areas such as RNs, Resp.Therapists,Pharmacists,perfusionists,etc. are but what I am starting to realize and the main reason I am a poster now instead of just lurking is you have a profession that was solely dependent on MD's and hospitals for their existence to now just because they have gone and taken some more classes that they should be called doctors or be equivalent to them. I did not even notice it before but it is really starting to show its ugly head even here where I practice. I think EtherMD is doing us a favor even if it does seem like his/her message seems all doom and gloom. If it was always positive then the establishment would not even look to change its position. Midlevels should and do have a place but it is under the direction or supervision of Medical Doctors and it is amazing that we are even here at this point having this type of discussion. I do think it is probably our faults though, the physicians should have seen this coming years ago and we should have taken notice we have been a little lazy in this respect but NO MORE.

 

[eutopia CRNA]

Sir, with all due respect, I do not think that I said that mid-levels are equivalent to physicians. In fact, I was very careful to include a qualification, that it is imperative that mid-levels have professionals (such as yourself) overseeing their action. The mere fact that you differentiate ascending cholangitis suggests that you acknowledge that there exists a gradient of complexity with respect to cases, to which the appropriately trained care-provider should be matched (otherwise, why not just say that you should be the only provider for a lap chole, period).

I don't think I should be ashamed of myself as a physician for being candid with the appropriate role I should play in a hospital, and certainly not for trying to expand my role as a perioperative physician. Furthermore, the purpose of my post is to refocus the discussion on the appropriate question: whether mid-levels, WITH THE APPARENTLY DIFFICULT TO UNDERSTAND CAVEAT OF SUPERVISION, can provide effective care IN SOME INSTANCES. If the answer to this question is yes, which I, unfortunately, think IN SOME INSTANCES is, we are being dishonest with ourselves and our patients insisting that we MUST be the only provider of their anesthetic, and by this I mean physically in the room 100% of the time, even if 90% of that time is surfing the web on our PDAs.

I bit of honesty. How refreshing. You are obviously one of those much loved and adored doc's that we all clamor to work with. One who respects our level of expertise and supports our presence. A true team player who is not threatened by that concept. Kudos to you. You should be very proud of yourself. I know my place in the team and it's not to act as physician, but as physician support in the realm of anesthesia.

 

[poster]

It's true, yes, we CRNA's to have the opportunity to receive doctorates in the field of anesthesia, making us Dr. Nurse. I am slated to become one of the first in Texas this next year. Texas Christian University is the first establishment in Texas to adopt this program and I'm on the list. I agree that a lot of the "old, crotchety, lazy" CRNA's may not want to extend themselves but as for the "young, happy, energetic" CRNA's like me out there....well, just try and stop us. As for staff, well, much of the teaching staff in CRNA programs are PhD's and MD's who also teach at the medical school level (bet you didn't know that). At least it was that way in my program. Anyway, these same fine people will be teaching the doctorate programs. How they will grandfather the old & crotchety, I don't know. I can tell you that it will be mandatory to have a doctorate in a few short years, just as the NP program will also become a doctorate. Yes, our salaries are CLIMBING like crazy, and I know it scares the daylights out of many of you. Rightfully so. You obviously have much more extensive training and your knowledge base is incredible. I look at myself as adjunct to the physician, not a replacement by any means. I know A LOT of CRNA's don't view it that way and think they are just as smart, clinically sound, etc. Just ain't so! (although there are a few SCARY anesthesiologists out there, and we've all met them). The moral of the story is.....great for us, not so great for ya'll. I really hate that too. It should be about team work not competition.

This is exactly the type of posts and mentality that the public should be made aware of. This type of thinking is just ridiculus. I do think that when this whole debate falls under a microscope the CRNA/ Anesthesiologist debate will end.

 

[Taurus]

Yes, our salaries are CLIMBING like crazy, and I know it scares the daylights out of many of you.

Your climbing salaries don't scare us per se. It's the growing awareness by Medicare that more and more anesthesia is given by nurses that really scares us. If the status quo today could last indefinitely, I doubt that physicians would be bitching that much. Everybody is making a lot of money. It's the future that has us really disturbed. CRNA's may be fattening their pockets today, but they are also laying the foundation for future troubles of their own. Once Medicare and insurance companies view anesthesia as a nursing profession, do you still think that your inflated salaries will hold up? It's high today because anesthesia is viewed as a physician's practice. You're riding our coattails. What happens when you have to stand on your own?

 

[eutopia CRNA]

what he is saying is complete and utter stupidity........

Internal medicine docs.. know that friggin algorhythm like the back of their hand.. thats all they do.. I dont care how long a nurse has been in the ER, they just dont got the training to run a code.. thats not waht they are trained to do.. and anyone who says that just dont know what theyre talking about or they just havent been around for any significant period of time.. maybe a med student or something.. wasnt robert a med student over the summer... see tats the problem.. many people very early in thier training are making comments about things they just dont know about. and thats where we have to gently correct them... I dont think he is a horrible person for saying that, he is just totally mis informed.. I am even wondering what he did during his internal medicine months

I must comment on this....with all your swill about your superior intelligence your message often gets a bit lost while trying to interpret ALL YOUR MISSPELLED WORDS. Honestly, isn't English on the MCAT? Goes to prove that ANYONE can pass a written test (there's that library learning again) but not everyone can pass the real life hands on test. Having worked in teaching hospitals for years, I rarely met a first year intern (who just completed ALL that library training!) who really knew how to apply all that knowledge in the real world UNTIL TAUGHT SO by hands on experience, which is something the RN (prior to becoming CRNA) does every single day in the ICU.

 

[eutopia CRNA]

I think conflicted, uregewrx and eutopia crna are the same person NITECAP. one of them is definitely nitecap, maybe all three

Ha!!!! I think that your over inflated ego makes it very difficult for you to realize that there may actually be 3 separate people who are intelligent pro-CRNA individuals. Too bad for you. Each of your comments just proves that statement I made earlier about that rare, elusive, "scarier than hell", doc that no one wants to work with. You must be very tired at the end of the day after lugging that huge ego around......as for thinking we are all one person, can you say "paranoid"?

 

[swpm]

It's true, yes, we CRNA's to have the opportunity to receive doctorates in the field of anesthesia, making us Dr. Nurse. I am slated to become one of the first in Texas this next year.

That's great! I have genuine respect for nurses (CRNA or not) who pursue additional, rigorous education and training. It can only improve the care they deliver to patients.

Here's the caveat though - while it will make you a better nurse, it will not make you a doctor.

Physicians should be supportive and encouraging to all health care professionals who choose to augment their knowledge base. But we must not pretend, or allow others to pretend, that anything other than medical school and residency can produce a doctor.

 

[eutopia CRNA]

Don't they have a law that says you need an MD/DO to be called "Doctor" in the clinical setting? Or is this a state-by-state thing?

No, officially we will not call ourselves Dr. We will be able write Dr. xyz when writing papers, etc. but could not present ourselves as Dr.'s in the medical setting. Rightfully so. That, in my eyes, would be very deceiving as lay person's do not understand the difference between MD vs. doctorate. That would make for very dangerous practice.

 

[EtherMD]

It's true, yes, we CRNA's to have the opportunity to receive doctorates in the field of anesthesia, making us Dr. Nurse. I am slated to become one of the first in Texas this next year. Texas Christian University is the first establishment in Texas to adopt this program and I'm on the list. I agree that a lot of the "old, crotchety, lazy" CRNA's may not want to extend themselves but as for the "young, happy, energetic" CRNA's like me out there....well, just try and stop us. As for staff, well, much of the teaching staff in CRNA programs are PhD's and MD's who also teach at the medical school level (bet you didn't know that). At least it was that way in my program. Anyway, these same fine people will be teaching the doctorate programs. How they will grandfather the old & crotchety, I don't know. I can tell you that it will be mandatory to have a doctorate in a few short years, just as the NP program will also become a doctorate. Yes, our salaries are CLIMBING like crazy, and I know it scares the daylights out of many of you. Rightfully so. You obviously have much more extensive training and your knowledge base is incredible. I look at myself as adjunct to the physician, not a replacement by any means. I know A LOT of CRNA's don't view it that way and think they are just as smart, clinically sound, etc. Just ain't so! (although there are a few SCARY anesthesiologists out there, and we've all met them). The moral of the story is.....great for us, not so great for ya'll. I really hate that too. It should be about team work not competition.

Thank You for the post. I am well aware of the PhD and soon to be DNAP title at the University/Medical School level. BY 2017 this will be required to be a CRNA instructor. Are you gong to be teaching SRNA's?

I believe older CRNA's will have options for bridging to the DNAP. In my Groyp a few bridged from BSN CRNA to M.S. CRNA while working for us. I expect the same for the DNAP.

 

[eutopia CRNA]

This is exactly the type of posts and mentality that the public should be made aware of. This type of thinking is just ridiculus. I do think that when this whole debate falls under a microscope the CRNA/ Anesthesiologist debate will end.

Please specify what is ridiculus about my post. Is it the fact that (god forbid) CRNA's might increase their education level! Or is it that it will mandatory in the future? I am confused by your comment? I cannot fathom how an increase in educational requirements would be ridiculus.

 

[EtherMD]

Your climbing salaries don't scare us per se. It's the growing awareness by Medicare that more and more anesthesia is given by nurses that really scares us. If the status quo today could last indefinitely, I doubt that physicians would be bitching that much. Everybody is making a lot of money. It's the future that has us really disturbed. CRNA's may be fattening their pockets today, but they are also laying the foundation for future troubles of their own. Once Medicare and insurance companies view anesthesia as a nursing profession, do you still think that your inflated salaries will hold up? It's high today because anesthesia is viewed as a physician's practice. You're riding our coattails. What happens when you have to stand on your own?

What level are you? Your grasp of the situation shows experience beyond your years?

 

[eutopia CRNA]

Your climbing salaries don't scare us per se. It's the growing awareness by Medicare that more and more anesthesia is given by nurses that really scares us. If the status quo today could last indefinitely, I doubt that physicians would be bitching that much. Everybody is making a lot of money. It's the future that has us really disturbed. CRNA's may be fattening their pockets today, but they are also laying the foundation for future troubles of their own. Once Medicare and insurance companies view anesthesia as a nursing profession, do you still think that your inflated salaries will hold up? It's high today because anesthesia is viewed as a physician's practice. You're riding our coattails. What happens when you have to stand on your own?

I really can't say. What I do know is that I am enjoying the ride right now, just as you are. We are all getting "fat" pockets out of the deal. When the bottom falls, it falls for ALL of us. Maybe instead of bickering about each other, we should try to work together to prevent that from happening, huh?

 

[eutopia CRNA]

That's great! I have genuine respect for nurses (CRNA or not) who pursue additional, rigorous education and training. It can only improve the care they deliver to patients.

Here's the caveat though - while it will make you a better nurse, it will not make you a doctor.

Physicians should be supportive and encouraging to all health care professionals who choose to augment their knowledge base. But we must not pretend, or allow others to pretend, that anything other than medical school and residency can produce a doctor.

Yes, I'm aware of that. And it was a JOKE (Dr. Nurse). As you'll see in another discussion I posted, I cannot ever use Dr. in a clinical setting and would NEVER want to misrepresent myself in such a manner.

 

[poster]

Please specify what is ridiculus about my post. Is it the fact that (god forbid) CRNA's might increase their education level! Or is it that it will mandatory in the future? I am confused by your comment? I cannot fathom how an increase in educational requirements would be ridiculus.

This is my point. CRNAs are arguing that they can perform with the same outcomes, anesthesia on the same level as physicians. Now when you all are making this statement and happily so with this great study you proclaim then you are saying that with the education you currently have, which at the time of the study was a BS degree only, you can perform anesthesia as well as a physician. If that is the case then why else would you put yourself through the rigors of more highly specialized classes, hmmmm maybe to better your argument for independent practice or maybe just to make yourself feel better. See I think it is selfishness and that you are trying to play doctor. Yes, increasing ones education is great and I am all for that but I truly believe that it is more of an agenda for the future. Since yall claim you provide the same quality care as physicians why else would there be a need to get a docorate when we all know that the reason is to feel like a doctor or be called a doctor or whatever you want to be called.

 

[EtherMD]

I really can't say. What I do know is that I am enjoying the ride right now, just as you are. We are all getting "fat" pockets out of the deal. When the bottom falls, it falls for ALL of us. Maybe instead of bickering about each other, we should try to work together to prevent that from happening, huh?

You want the answer: CRNA arrogance and the AANA.

The AANA keeps pushing the envelope for FULL EQUIVALENCE legally and clinically with the MD. The DNAP is the last straw in the AANA's battle for full independence from the MD. The problem is this may "back-fire" on you big time.

If Anesthesia is viewed as Nursing by Medicare and insurance carriers expect a 50% or more pay cut. Also, expect the ASA and the ABA to launch a counter-attack like you have never seen before. This could result in a back-lash against any type of CRNA anesthesia. You realize that Physicians will be prefered over Nurses every time by the lay public.

Don't forget the AA equation. At some point the ASA and Academic Chairs make wake up and start a big campaign to replace as many CRNA's as possible with AA's.

All of this avoidable. CRNA's now make as much as $300,000 per year.
Why mess with success? The GREED of the AANA will be its undoing.

 

[Taurus]

What level are you? Your grasp of the situation shows experience beyond your years?

I'm a second year medical student.

I have a good grasp of how things work outside of medicine though. I worked for a few years in the trading world. That's a good place to appreciate what unfettered, free market is really like. I understand the driver behind the encroachment of midlevels and why anesthesiology has to do something before it's too late. I don't know if midlevels understand that they're really hurting themselves in the long run if they push physicians out of the OR. Even with a DNAP, it's not a medical degree. Somehow, they believe that they deserve the 200k per year for their master's degree. They're getting that level of income because of involvment of the physician. Once more schools open for CRNA's and AA's and Medicare cuts reimbursements to the bone because it looks at anesthesia as a nursing profession, I expect to see unemployed or very bitter CRNA's in the future. They'll be crying that they thought it would last indefinitely.

 

[eutopia CRNA]

Thank You for the post. I am well aware of the PhD and soon to be DNAP title at the University/Medical School level. BY 2017 this will be required to be a CRNA instructor. Are you gong to be teaching SRNA's?

I believe older CRNA's will have options for bridging to the DNAP. In my Groyp a few bridged from BSN CRNA to M.S. CRNA while working for us. I expect the same for the DNAP.

As one of the first doctorate grads, I will probably find myself teaching someday. I will want to give back to my profession. There are programs that bridging from BSN to PhD now. They are 7-8 year programs. The program I am entering is a 3-4 year program depending on how quickly you want to complete the degree. Courses include such subjects as epidemiology, biochemistry, etc. Not just basic nursing stuff. This program is very unlike the current PhD's in nursing. They are more science and research based than the current nursing PhD's that are heavy nursing research based.

 

[SexPanther]

I really can't say. What I do know is that I am enjoying the ride right now, just as you are. We are all getting "fat" pockets out of the deal. When the bottom falls, it falls for ALL of us. Maybe instead of bickering about each other, we should try to work together to prevent that from happening, huh?

That's precisely the point that Ether, Taurus and others (including myself) are trying to make. The AANA should embrace the ACT model of anesthesia and quit with the militant CRNA = MD/DO b/c it is the way to ensure continued financial success. Reimbursement will only continue to run as high as it has if gas is considered a physician specialty.

 

[eutopia CRNA]

This is my point. CRNAs are arguing that they can perform with the same outcomes, anesthesia on the same level as physicians. Now when you all are making this statement and happily so with this great study you proclaim then you are saying that with the education you currently have, which at the time of the study was a BS degree only, you can perform anesthesia as well as a physician. If that is the case then why else would you put yourself through the rigors of more highly specialized classes, hmmmm maybe to better your argument for independent practice or maybe just to make yourself feel better. See I think it is selfishness and that you are trying to play doctor. Yes, increasing ones education is great and I am all for that but I truly believe that it is more of an agenda for the future. Since yall claim you provide the same quality care as physicians why else would there be a need to get a docorate when we all know that the reason is to feel like a doctor or be called a doctor or whatever you want to be called.

It's not about being a doctor, it's about being a highly educated anesthetist. If you are threatened by that concept I am very sorry. I never was a B.S. CRNA. And CURRENT mortality & morbidity still shows no increase with CRNA vs. MD. Maybe you should subscribe........

 

[eutopia CRNA]

You want the answer: CRNA arrogance and the AANA.

The AANA keeps pushing the envelope for FULL EQUIVALENCE legally and clinically with the MD. The DNAP is the last straw in the AANA's battle for full independence from the MD. The problem is this may "back-fire" on you big time.

If Anesthesia is viewed as Nursing by Medicare and insurance carriers expect a 50% or more pay cut. Also, expect the ASA and the ABA to launch a counter-attack like you have never seen before. This could result in a back-lash against any type of CRNA anesthesia. You realize that Physicians will be prefered over Nurses every time by the lay public.

Don't forget the AA equation. At some point the ASA and Academic Chairs make wake up and start a big campaign to replace as many CRNA's as possible with AA's.

All of this avoidable. CRNA's now make as much as $300,000 per year.
Why mess with success? The GREED of the AANA will be its undoing.

Do you suppose that all CRNA's think that way? Arrogance seems to be reserved by you and your croonies who think like you. The audacity to think that only a physician could ever be skilled enough to deliver anesthesia! Maybe what you REALLY fear is that it's true, CRNA's are capable of delivering anesthesia safely. Heaven forbid!!!! I do not want to be a doctor. I love what I do, and I want to improve at it. Please don't knock me for that. I don't agree with everything the AANA presumes to do. As in any organization, the political agenda often ruins the true meaning of the groups actions. I just want to increase my knowledge base. Becoming a PhD will increase my salary somewhat, but not enough to make a huge impact. In fact, the cost of my education off sets that increase greatly. I am not doing this for more power or money, but rather for my PATIENTS benefit. You see, the more knowledgable I am the safer care I can deliver. In my world it's all about the patient and their outcome. What's it about in your world?

 

[eutopia CRNA]

I'm a second year medical student.

I have a good grasp of how things work outside of medicine though. I worked for a few years in the trading world. That's a good place to appreciate what unfettered, free market is really like. I understand the driver behind the encroachment of midlevels and why anesthesiology has to do something before it's too late. I don't know if midlevels understand that they're really hurting themselves in the long run if they push physicians out of the OR. Even with a DNAP, it's not a medical degree. Somehow, they believe that they deserve the 200k per year for their master's degree. They're getting that level of income because of involvment of the physician. Once more schools open for CRNA's and AA's and Medicare cuts reimbursements to the bone because it looks at anesthesia as a nursing profession, I expect to see unemployed or very bitter CRNA's in the future. They'll be crying that they thought it would last indefinitely.

Hmmmm, do you mean just like the doc's are doing right now? Seems that there are some very bitter doc's out there who "thought it would last indefinitely" too. I can remember a time when the salaries were double what they are in anesthesia, but that changed after CRNA's came along.

 

[The_Sensei]

making us Dr. Nurse....

I will NEVER call a nurse "doctor" no matter how many PhD's they have!

 

[Taurus]

What I do know is that I am enjoying the ride right now, just as you are. We are all getting "fat" pockets out of the deal. When the bottom falls, it falls for ALL of us.

Unfortunately, too many CRNA's have this myopic view.

Unfortunately, too many anesthesiologists are apathetic.

We live in the land of living for today and worrying about the future tomorrow. We hunt animals to the brink of extinction and then try to save them from extinction. We buy stock and houses because we think it will go up forever, but what happens when the music stops?

 

[eutopia CRNA]

I think it is very interesting, and sad, that many of you seem to delight in the idea that AA's will replace CRNA's. Why is it that doc's seem less threatened by a PA than a NP, or an AA than a CRNA? It seems that it just irks you guys to no end to have a NURSE (yes, God forbid, a common, lowly nurse) have any status in this world at all. Whereas a PA or AA, well that's different, right? Listen, PA's have no better training than NP's, and AA's will be the same as CRNA's. And guess what gang....that's not a threat to us. They will work as part of the team doing the same job. More power to them. I think it's great too. Because they will be on equal footing with us and that gives us strength in numbers. Oh yeah, since part of the team will NOT be nurses, it will be even more difficult to view mid-level anesthesia as nurse driven in the future. So actually, the presence of AA's will only help secure our financial stability.