More CRAP from the AANA....

[The_Sensei]

New Study Shows OB Anesthesia Equally Safe When
Provided by CRNAs or Anesthesiologists

Park Ridge, Ill.—Obstetrical anesthesia, whether provided by Certified Registered Nurse Anesthetists (CRNAs) or anesthesiologists, is extremely safe, and there is no difference in safety between hospitals that use only CRNAs compared with those that use only anesthesiologists, according to the results of a new study published in the January/February issue of Nursing Research (Vol. 56, No. 1, pp. 9-17).

The study, titled "Anesthesia Staffing and Anesthetic Complications During Cesarean Delivery" ( www.nursingresearchonline.com ), was a retrospective analysis undertaken by Daniel Simonson, CRNA, MHPA, chief anesthetist and managing partner of The Spokane Eye Surgery Center in Spokane, Wash.; Melissa Ahern, PhD, MBA, associate professor, Department of Health Policy and Administration, Washington State University, Spokane; and Michael Hendryx, PhD, associate professor, Department of Community Medicine, and research director, Institute of Health Policy Research, West Virginia University School of Medicine, Morgantown, W.V.

Simonson and his fellow researchers set out to identify differences in the rates of anesthetic complications for cesarean section in hospitals where the OB anesthesia is provided solely by CRNAs compared to hospitals where the OB anesthesia is provided solely by anesthesiologists in the state of Washington.

The results showed that there is no difference in rates of complications between hospitals that use only CRNAs compared with those that use only anesthesiologists. No difference was found in mortality rates either.

"The study results clearly demonstrate that OB anesthesia complications are no different between the CRNA-only and anesthesiologist-only staffing models," Simonson said. "Expectant mothers can have great confidence knowing that they and their babies will be safe in the care of a nurse anesthetist or an anesthesiologist.

"Further, hospital administrators and anesthesiology groups can comfortably consider variables other than provider safety or quality—such as provider availability, cost, and the percentage of Medicaid patients cared for at their facility—when staffing for obstetrical anesthesia," Simonson added.

The study involved 134,806 patients, including 33,236 who were cared for at hospitals whose OB anesthesia was staffed by CRNAs only, and 101,570 who were cared for at hospitals staffed by anesthesiologists only. Washington state hospital discharge data for 1993-2004 were obtained from the Comprehensive Abstract and Reporting System database and merged with data from a survey of anesthesia or medical staff at the two types of hospitals.

In the study sample there were 965 anesthetic complications and 17 deaths: 76 percent of the complications were classified as less serious according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), and only one of the deaths had an ICD-9-CM code associated with an anesthetic complication. The CRNA-only hospitals had a complication rate of 0.58 percent, while the anesthesiologist-only hospitals had a rate of 0.76 percent.

Regression analysis was used to adjust for independent variables such as hospital characteristics (geographic location, size, and teaching status), patient demographics (ages, primary payer, and type of admission), and patient commorbidities.

Several interesting patterns emerged from the data. The CRNA-staffed hospitals treated the greatest percentage of Medicaid, rural, teaching, urgent admission, and very young (under 17 years old) patients, while anesthesiologist-staffed hospitals had the greatest percentage of emergency admissions and older mothers (over 35 years old). Additionally, a substantially higher percentage of sicker patients were transferred to CRNA-only hospitals, a factor which could, potentially, affect the number of anesthetic complications at a facility. However, this did not prove to be the case.

"Hospitals and anesthesiology groups, particularly those in rural areas and those in medically underserved urban areas with large Medicaid populations, now have a possible long-term solution to their OB anesthesia staffing needs: greater use of CRNAs working without anesthesiologist supervision," Simonson said. He added that further studies are needed to validate the observations made from this study.

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[Planktonmd]

This is giving me severe nausea!

 

[RockLee]

Alright. I've been reading these posts about CRNA's vs. Anesthesiologists for awhile now...haven't really posted.

But this article ... wtf? OB Anesthesia is one of the last place that I would allow a CRNA to work.

 

[blocks]

You just stop training SNRA's and all this goes away. Period.

 

[badgas]

You just stop training SNRA's and all this goes away. Period.

I agree. Won't fix the whole problem but it is a great start.

 

[EtherMD]

You just stop training SNRA's and all this goes away. Period.

You hit the nail on the head. YOUR leadership and Academic Chairs are selling you out for cheap labor. If the Academic Chairs converted all the CRNA programs into AA Programs (not as easy as it sounds) then the AANA wouldn't be graduating record numbers of new anesthetists. The Academic Chairs are cutting your throats and dooming the specialty. As usual our worst enemy is ourselves.

Leave the CRNA programs for the community hospitals. Build First Tier AA Programs at the Universities now before the AANA wins the war. More of these crap studies are coming your way for surgicenters, eye cases, etc.
Imagine how much more aggressive the AANA is going to get when it requires a PhD for its new graduates. That's when the final push for complete control
of the anesthesia market place will occur. In my opinion, we have 5-10 years to get our sh#@ together or the specialty is finished as we know it.

 

[SleepIsGood]

WOW

it's coming for all those nay sayers.

Now, is replacing the CRNAs with AA's the right choice? Remember they are also paraprofessionals.

This is a slap in the face to ALL of us ! We need to have the ASA put out articles, propaganda to counter this. We dont directly have to bash the CRNAs, just raise awareness.

What have I been doing which I think helps. When you guys go see patients on the floor and they see that you are with Anesthesiology give them a little talk about what you all do. Almost without a doubt ppl tell me, "wow you're an anesthesiologist, you must have high liability and it's soo dangerous". I take that opportunity to tell them that it can be dangerous. People like the dentist a few months back think it's a joke to be sedating patients outside the hospital. Nurses feel that they can sedate patients just as good. I tell them that these non-MD's perform these sedations and anesthestics because they are trying to cut costs and make money for themselves. Stuff can go wrong easily and very fast. Death can occur. Anesthesiologists however know when to recognize when things can go wrong and can fix it easily. Most surgeries done by anesthesiologists produce few complications and is relatively safe.

I then tell them how there can be many things that can go wrong and that we are trained to protect the airway which is the main concern in almost any code situation. I then offer them the choice, who would you like doing your anesthesia a doctor or a nurse? I always get a vehement, "doctor". I tell them that yes I'm a little biased as well, but I would also want a physician taking care of my loved one because I can trust that they have been properly educated. I then tell them to remember to ask the anesthesia staff/surgeons in the unlikely event of a surgery whether their anesthesiology staff is 100% physician ran. I tell them to make sure that it's a medical doctor (anesthesiologist) and not a nurse or 'anesthesist".

Seriously, our little propaganda can start with EACH of you educating atleast one or two patients each day about how important an anesthesiologist is. These patients will for sure go out into the community and spread the word themselves.

#2-It's not just the academics that create these CRNAs...it's also the groups/attendings that HIRE them. I know atleast 2 group leaders of 2 different anesthesia groups that told me that they could have made more money if they hired some CRNAs but they didnt out of principle. Plus they said surgeons, especially the old school ones love the fact that their group is MD only w/o any CRNAs. It's a marketing tool they utilize.

Remember folks. You guys went to med school and received those initials after your name and you're the one that wears that white coat (well mostly nowadays...new topic). When ppl here you talk they will listen to you. It's about how articulately you tell your patients things. Do the right thing and inform your patients now. This applies to even you medical students out there! It's a business world out there. It's about who can advertise and produce better propaganda. Doctors need to realize its not taboo anymore to advertise, in fact if we dont, the absurdness written by the CRNAs is all that the public has to go by. Open your mouths and reach out!

 

[Be a Pro]

I absolutely agree with the above post. How can the ASA sit on the sidelines like this? I totally agree if informed and given the choice -- mothers would choose doctors-- at least doctor supervision. The public, as Sleep has said, needs to be prompted to ask. In their bill of rights there should be an amendment stating that patients should be aware of the qualifications --- maybe with signed consent -- of their providers.

 

[sallyjoe]

You just stop training SNRA's and all this goes away. Period.

They don't learn epidurals while they are SNRAs.

I worked for a rather nasty employer who refused to pay the prevailing wages for CRNAs and who lost most experienced CRNAs in a few months due to his poor working conditions awful attitude.

This employer started recruiting new graduate CRNAs since they would work for less not quit immediately.

I got to train these new CRNAs or GRNAs until they passed the test They came to our place having only placed only one or two epidurals and less than ten spinals total. Having worked with new CRNAs from a number of schools this is typical of the level of experience a NEW graduate CRNA brings to OB. One place we had a new CRNA who the OB nurses labeled as incompetent at epidurals due to her numerous wet taps, so we would not tell the ob department that she was on call so we could get at least one epidural for her to try before the nurses stopped calling for epidurals that night for fear of the harm she would do to their patients

 

[EtherMD]

They don't learn epidurals while they are SNRAs.

I worked for a rather nasty employer who refused to pay the prevailing wages for CRNAs and who lost most experienced CRNAs in a few months due to his poor working conditions awful attitude.

This employer started recruiting new graduate CRNAs since they would work for less not quit immediately.

I got to train these new CRNAs or GRNAs until they passed the test They came to our place having only placed only one or two epidurals and less than ten spinals total. Having worked with new CRNAs from a number of schools this is typical of the level of experience a NEW graduate CRNA brings to OB. One place we had a new CRNA who the OB nurses labeled as incompetent at epidurals due to her numerous wet taps, so we would not tell the ob department that she was on call so we could get at least one epidural for her to try before the nurses stopped calling for epidurals that night for fear of the harm she would do to their patients

All CRNA's finish their training weak in one or two ares. Usually, it is Epidural and central line placement but not always. The one's who graduate from a top CRNA school are better than one's who finish a bottom program.

Most develop their skills on the job over a few years. I taught several CRNA's to do Epidurals and they now are good to excellent at them. After a decade of regular Epidural placements they are better than most new graduate MDA's.

 

[blocks]

You hit the nail on the head. YOUR leadership and Academic Chairs are selling you out for cheap labor. If the Academic Chairs converted all the CRNA programs into AA Programs (not as easy as it sounds) then the AANA wouldn't be graduating record numbers of new anesthetists. The Academic Chairs are cutting your throats and dooming the specialty. As usual our worst enemy is ourselves.

Leave the CRNA programs for the community hospitals. Build First Tier AA Programs at the Universities now before the AANA wins the war. More of these crap studies are coming your way for surgicenters, eye cases, etc.
Imagine how much more aggressive the AANA is going to get when it requires a PhD for its new graduates. That's when the final push for complete control
of the anesthesia market place will occur. In my opinion, we have 5-10 years to get our sh#@ together or the specialty is finished as we know it.

A fitting analogy for all the critical care folks: source control. You can treat with IV ABX all you want, but unless you remove that gangrenous leg, the infection will eventually kill you. Time to man up.

 

[blocks]

All CRNA's finish their training weak in one or two ares. Usually, it is Epidural and central line placement but not always. The one's who graduate from a top CRNA school are better than one's who finish a bottom program.

Most develop their skills on the job over a few years. I taught several CRNA's to do Epidurals and they now are good to excellent at them. After a decade of regular Epidural placements they are better than most new graduate MDA's.

Gee whiz, that's nice that the CRNAs that you have been teaching to do epidurals are eventually good enough to provide a cheaper alternative to new residency graduates.

 

[augmel]

is anyone going to critique the paper? if this is really bull**** it shouldn't be hard to point out the methodology flaws. anyone have access to the original paper? I've always thought that one of the biggest differences between docs and nurses is quality of literature and ability to interpret.

 

[The_Sensei]

I taught several CRNA's to do Epidurals and they now are good to excellent at them. After a decade of regular Epidural placements they are better than most new graduate MDA's.

I highly recommend that NO physicians train CRNAs in spinals, epidurals, central lines or regional anesthesia. Where I work the physicians do all the above. We should maintain AT LEAST some degree of separation between what we and the CRNAs do. Why would you willingly train someone who could potentially compete for a job with a future graduate? Deplorable...

 

[bestiller]

OB reimbursement is such a stinker(Medicaid), ie time vs income, that it is handed to the AA or CRNA. In my group MD's never touch 98% of the OB and "call" is 100% CRNA done b/c when broken down it was merely 15% of our groups income and the CRNA contractually signed over 50% of that billing.

 

[coccygodynia]

The SRNA program near me spends a month on an OB floor doing nothing except spinals and epidurals. I think they average about 50 placements before graduating.

 

[EtherMD]

I highly recommend that NO physicians train CRNAs in spinals, epidurals, central lines or regional anesthesia. Where I work the physicians do all the above. We should maintain AT LEAST some degree of separation between what we and the CRNAs do. Why would you willingly train someone who could potentially compete for a job with a future graduate? Deplorable...

Some of us do what is necessary to keep our jobs and run our practice. In my hospital more than 50% of Epidurals are Medicaid or no pay. There is no way we could afford a full-time MDA dedicated to OB. So, we utilize a CRNA with MDA supervision. We assist when needed and train a few CRNA's as needed (when one leaves we train another) to do Epidurals. We are present for all C-sections and during the day we do a few Epidurals as well. But, by having a CRNA dedicated to OB 24/7 it makes good fiscal sense. With a poor payer mix we are still able to provide the service and retain back-up MDA coverage (in house).

If the law allowed AA's to do this sort of thing then we could utilize them.
However, there are few AA's available at this time and the laws for allowing AA's to do an Epidural without the presence of an MDA are vague. With the CRNA's the law is perfectly clear that they can place an Epidural without the physical presence of an MDA in the room.

So, one has to balance real world economics with philosophical beliefs. This is what politicians and our ASA leadership has to deal with all the time. My Group does not train new student Nurse Anesthetist nor do we believe a CRNA should be allowed "Independent" Practice but we do employ CRNA's.
I believe there is a role for Mid-level Providers in Anesthesia under the direction of an MDA. Perhaps, the AA's can restore that role without threatening job security.

 

[johankriek]

Some of us do what is necessary to keep our jobs and run our practice. In my hospital more than 50% of Epidurals are Medicaid or no pay. There is no way we could afford a full-time MDA dedicated to OB. So, we utilize a CRNA with MDA supervision. We assist when needed and train a few CRNA's as needed (when one leaves we train another) to do Epidurals. We are present for all C-sections and during the day we do a few Epidurals as well. But, by having a CRNA dedicated to OB 24/7 it makes good fiscal sense. With a poor payer mix we are still able to provide the service and retain back-up MDA coverage (in house).

If the law allowed AA's to do this sort of thing then we could utilize them.
However, there are few AA's available at this time and the laws for allowing AA's to do an Epidural without the presence of an MDA are vague. With the CRNA's the law is perfectly clear that they can place an Epidural without the physical presence of an MDA in the room.

So, one has to balance real world economics with philosophical beliefs. This is what politicians and our ASA leadership has to deal with all the time. My Group does not train new student Nurse Anesthetist nor do we believe a CRNA should be allowed "Independent" Practice but we do employ CRNA's.
I believe there is a role for Mid-level Providers in Anesthesia under the direction of an MDA. Perhaps, the AA's can restore that role without threatening job security.

where do you live?

 

[Stimulate]

I am guessing that Nursing Research is not quite up there with NEJM or Anesthesiology. If I were publishing this kind of crap and I were trying to stick to the anesthesiologists, don't you think I would try to put this into a reputable journal, especially one actually READ by the anesthesia community?? I would wager that the authors tried to submit to quality anesthesia journals but that there were major flaws in the design of the study and they were summarily rejected. (I don't have access to that particular journal, nor would I suppose to EVER want access to that journal, so I can't comment on the merits of its design but why else would you publish in a rag journal.) Just my 2 cents.

In a high-risk specialty like obstetrics I doubt that you will see anesthesiologists being laid-off to hire CRNAs. If I were an obstetrician I would insist on having a physician involved in the management of my patients, especially if there is no cost difference to me personally. Keep in mind that even in those states where CRNAs practice without anesthesiologist's supervision, they ARE practicing under the OB's supervision (legally) and therefore when badness happens he/she will have SOLE responsibility in court. At least with another physician involved you can share in the misery.

Lastly, I still recommend that anesthesiologists in training complete a fellowship that will distinguish them from nurses (pain, peds, cardiac, critical care). My vision of what will happen within 15 years is this: The AANA will extract favorable data from the 19 (I think it is 19) states that allow CRNAs to practice under non-anesthesiologist supervision; they will use that data to eventually gain this right in all 50 states. Once they have secured this right in all 50 states, the insurers will redefine anesthesiology as the practice of nursing and use that to cut reimbursement drastically. Less physicians will pursue anesthesiology as a career, CRNA programs will continue to increase their size of graduating classes and add more programs, and they will further increase their domination.

We can partially blame ourselves for this problem but also we can blame the fact that anesthetics are becoming too safe. With some of the new airway management tools coming out, our skills are becoming less important. I can practically intubate someone from home with a glidescope. The days of making $500K for maintaining normal vitals while the surgeons operate are numbered.

 

[CremeSickle]

Hey stimulate

I just read that study after seeing that short blurb on it here.

Since its not up to your expectations. Why dont you critique it for me.
Whats wrong with the P and N values?
Why is where they got the data so bad?
Where is the flawed methodology in a retrospective analysis of the data?

Come now. This is like a bash fest without a shread of evidence and everyone seems to forget the VAST amount of medical research that is absolutly bollox comming out EVERY YEAR paid for by drug companies in our Anesthesiology journal and many others.

 

[EtherMD]

I am guessing that Nursing Research is not quite up there with NEJM or Anesthesiology. If I were publishing this kind of crap and I were trying to stick to the anesthesiologists, don't you think I would try to put this into a reputable journal, especially one actually READ by the anesthesia community?? I would wager that the authors tried to submit to quality anesthesia journals but that there were major flaws in the design of the study and they were summarily rejected. (I don't have access to that particular journal, nor would I suppose to EVER want access to that journal, so I can't comment on the merits of its design but why else would you publish in a rag journal.) Just my 2 cents.

In a high-risk specialty like obstetrics I doubt that you will see anesthesiologists being laid-off to hire CRNAs. If I were an obstetrician I would insist on having a physician involved in the management of my patients, especially if there is no cost difference to me personally. Keep in mind that even in those states where CRNAs practice without anesthesiologist's supervision, they ARE practicing under the OB's supervision (legally) and therefore when badness happens he/she will have SOLE responsibility in court. At least with another physician involved you can share in the misery.

Lastly, I still recommend that anesthesiologists in training complete a fellowship that will distinguish them from nurses (pain, peds, cardiac, critical care). My vision of what will happen within 15 years is this: The AANA will extract favorable data from the 19 (I think it is 19) states that allow CRNAs to practice under non-anesthesiologist supervision; they will use that data to eventually gain this right in all 50 states. Once they have secured this right in all 50 states, the insurers will redefine anesthesiology as the practice of nursing and use that to cut reimbursement drastically. Less physicians will pursue anesthesiology as a career, CRNA programs will continue to increase their size of graduating classes and add more programs, and they will further increase their domination.

We can partially blame ourselves for this problem but also we can blame the fact that anesthetics are becoming too safe. With some of the new airway management tools coming out, our skills are becoming less important. I can practically intubate someone from home with a glidescope. The days of making $500K for maintaining normal vitals while the surgeons operate are numbered.

I agree with you somewaht. There are 14 states that participate in "opt-out"
allowing Independent CRNA practice. While the scenario you describe is possible there are other alternatives: 1) the ASA wakes up and begins 10-12 new AA programs over the next two years 2) The ASA starts a vigorous campaign to explain the value of Anesthesiologists and the fact that it is the world standard including England and Canada! 3) the ASA working with the academic chairs closes many academic CRNA programs 4) MDA's begin to hire AA's in large numbers and the AANA's core membership begins to panic
5) A truce is declared and the AANA issues a statement that the Anesthesia Care Team is the prefered model in large hospitals

However, I agree that one or even two fellowships are a good idea for the next decade in case things don't go well for the ASA. AA's are our best shot at reigning in the AANA and the CRNA's; we must show them they are the ones who will be replaced if they continue to oppose us. This must happen soon or we lose the opportunity to effect their behavior. I know for a fact that many of the AANA's rank and file will be quite upset and panic at the thought of more AA's in the work place. The "average" CRNA knows that the MDA's are better and run the show. With AA's as an alternative the AANA is going to feel the heat from its membership. If we act NOW as a society (ASA) and with our academic leadership (university programs) we can still WIN! Shut the CRNA programs DOWN and start AA programs. This will be the shot heard loudly at the AANA. They have declared war with us OPENLY; we must fight back or be slaughtered like sheep. The apathy must stop soon or it is going to let the AANA kill us as a specialty.

 

[toughlife]

Hey stimulate

I just read that study after seeing that short blurb on it here.

Since its not up to your expectations. Why dont you critique it for me.
Whats wrong with the P and N values?
Why is where they got the data so bad?
Where is the flawed methodology in a retrospective analysis of the data?

Come now. This is like a bash fest without a shread of evidence and everyone seems to forget the VAST amount of medical research that is absolutly bollox comming out EVERY YEAR paid for by drug companies in our Anesthesiology journal and many others.

How many times do you need to be reminded that the CRNA forum is at www.allnurses.com

 

[CremeSickle]

AH yes

If i dont agree with the hypocrisy i MUST be a CRNA.

You are nothing to me TL, get over yourself.

 

[toughlife]

AH yes

If i dont agree with the hypocrisy i MUST be a CRNA.

You are nothing to me TL, get over yourself.

Yes and Ditto

 

[johankriek]

I am guessing that Nursing ResearchLastly,

I still recommend that anesthesiologists in training complete a fellowship that will distinguish them from nurses (pain, peds, cardiac, critical care).
We can partially blame ourselves for this problem but also we can blame the fact that anesthetics are becoming too safe. With some of the new airway management tools coming out, our skills are becoming less important. I can practically intubate someone from home with a glidescope. The days of making $500K for maintaining normal vitals while the surgeons operate are numbered.

I said it before when ethermd said it.. I dont need a fellowship to distinguish myself from a nurse and if YOU do, then you need to re-evaluate yourself as a physician.

If anesthetics are soo safe why dont we let a monkey do it? or the surgeon for that matter.....Why are you suggesting fellowship training? if its so safe.. forty eight months and 3500 anesthetics is not enough. The truth is... no matter how safe.. you need physician to evaluate the patient preop.. and you need a physician to tell the surgeon when he is in over his head.. a nurse cannot do this..

 

[Stimulate]

Hey stimulate

I just read that study after seeing that short blurb on it here.

I am sorry that you read the study for that is 10 minutes of your life that you will never get back.

Prior to even reading a study that is quoted, I look at the quality of the journal. I do not consider Nursing Research to be an authoritative source of information relating to the practice of anesthesiology, and therefore why would I waste my time reading it. And yes I do feel some level of sympathy for the authors who weren't able to get it published in a quality journal, but I don't read articles out of sympathy (or at your request).

Next, I strongly believe that CRNAs need to practice under the supervision of an anesthesiologist. The problem is that the politicians do not want to pay for anesthesiologists, and that message is loud and clear. Why were academic anesthesiology programs singled out by Medicare in 1992 (I am referring to the 50% cut in payment when residents are involved in management of Medicare patients)? This policy is largely responsible for the decline in numbers of anesthesiology teaching programs. CMS has actually incentivized hospitals to close residency programs and use attending-only, CRNAs, or even SRNAs (they are all reimbursed at 100%). ASA has tried for years to fix this problem but every time the AANA manages to block their efforts. CMS will not change the rule so literally an act of congress is needed to correct this problem. And guess what? AANA managed to block the legislation at the last minute this year. AANA wants to see the number of anesthesiologists to decline while their numbers increase.

Bottom line is that there is a big squeeze coming in healthcare funding over the next 10-15 years and unless anesthesiologists either a) expand their role in peri-operative management or b) provide irrefutable evidence that better outcomes occur with their supervision, further payment cuts and expansion of CRNA practice rights will continue.

AANA has absolutely declared war on anesthesiologists and they have several advantages:
a) strength in numbers (more CRNA graduates per year than residents and they opening new programs whereas we are closing programs down due to the Medicare Teaching Rule...50% cut)
b) better lobbying efforts (even congressman will tell you that!)
c) higher percentages of members who contribute to their lobbying efforts (we are cheap!!!! Residents and attendings complain about CRNAs and when you ask them, it is surprising how few actually contribute to their PACs and ASA.) .

Lastly, the individual who said he/she doesn't feel the need to distinguish themself from a nurse... It is great that you have such high self-esteem. However, apathy is just the type of attitude that can be dangerous. These are the anesthesiologists whom the AANA loves...Those who believe, "I am a physician so I must be better". These people ride the wave of apathy and do little to guard the profession while groups like AANA work behind the scenes to sabotage the future of the specialty. The specialty will probably be fine for at least 10 years or so but I still do not see the harm in obtaining a year of extra training that will increase your job prospects, help you better take care of that subset of patients, and set you apart from the CRNAs.

 

[EtherMD]

I am sorry that you read the study for that is 10 minutes of your life that you will never get back.

Prior to even reading a study that is quoted, I look at the quality of the journal. I do not consider Nursing Research to be an authoritative source of information relating to the practice of anesthesiology, and therefore why would I waste my time reading it. And yes I do feel some level of sympathy for the authors who weren't able to get it published in a quality journal, but I don't read articles out of sympathy (or at your request).

Next, I strongly believe that CRNAs need to practice under the supervision of an anesthesiologist. The problem is that the politicians do not want to pay for anesthesiologists, and that message is loud and clear. Why were academic anesthesiology programs singled out by Medicare in 1992 (I am referring to the 50% cut in payment when residents are involved in management of Medicare patients)? This policy is largely responsible for the decline in numbers of anesthesiology teaching programs. CMS has actually incentivized hospitals to close residency programs and use attending-only, CRNAs, or even SRNAs (they are all reimbursed at 100%). ASA has tried for years to fix this problem but every time the AANA manages to block their efforts. CMS will not change the rule so literally an act of congress is needed to correct this problem. And guess what? AANA managed to block the legislation at the last minute this year. AANA wants to see the number of anesthesiologists to decline while their numbers increase.

Bottom line is that there is a big squeeze coming in healthcare funding over the next 10-15 years and unless anesthesiologists either a) expand their role in peri-operative management or b) provide irrefutable evidence that better outcomes occur with their supervision, further payment cuts and expansion of CRNA practice rights will continue.

AANA has absolutely declared war on anesthesiologists and they have several advantages:
a) strength in numbers (more CRNA graduates per year than residents and they opening new programs whereas we are closing programs down due to the Medicare Teaching Rule...50% cut)
b) better lobbying efforts (even congressman will tell you that!)
c) higher percentages of members who contribute to their lobbying efforts (we are cheap!!!! Residents and attendings complain about CRNAs and when you ask them, it is surprising how few actually contribute to their PACs and ASA.) .

Lastly, the individual who said he/she doesn't feel the need to distinguish themself from a nurse... It is great that you have such high self-esteem. However, apathy is just the type of attitude that can be dangerous. These are the anesthesiologists whom the AANA loves...Those who believe, "I am a physician so I must be better". These people ride the wave of apathy and do little to guard the profession while groups like AANA work behind the scenes to sabotage the future of the specialty. The specialty will probably be fine for at least 10 years or so but I still do not see the harm in obtaining a year of extra training that will increase your job prospects, help you better take care of that subset of patients, and set you apart from the CRNAs.

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Agree with you 100%. Volatile, Stimulate and I are not the same person but we do have similar ideas and feelings about many issues.

 

[Stimulate]

I hate to paint such a bleak picture of anesthesiology but everything is going to come down to money in the long run.

The CRNAs need to be worried as well. Lets say for example that the CRNAs succeed in eliminating anesthesiologists by gaining practice rights in all 50 states. CMS, Congress, the White House will support this as long as it seems "safe" and cost-effective. But the politicians and insurers are helping the CRNAs now because they are looking at the big picture. They are looking at the benefits for their budgets once they take the PHYSICIANS out of the picture.

Insurers will NOT continue to pay for physician-level reimbursements ($60/unit or $240/hour) for "the practice of nursing". There is no way that CRNAs will be able to retain that level of reimbursement. The only reason that reimbursement is relatively good in anesthesiology (for CRNAs and physicians)is that there is PHYSICIAN involvement. If that is taken away then of course payment cuts will follow. This is why the Anesthesia Care Team model needs to continue. It is to all of our benefit to peacefully co-exist. We are wasting our efforts battling each other when we should be battling insurers and Medicare for payment updates.

 

[SleepIsGood]

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Agree with you 100%. Volatile, Stimulate and I are not the same person but we do have similar ideas and feelings about many issues.

not to seem harsh folks...but this "all it is is another year of education" bantering is quite ridiculous. yes, we are in medicine and we are ALL life long learners, but since when did we hear those words, "it's just a little more education". We've heard it in high school, then college, then med school, and now residency. ppl want to extend residency? Why not include CCM/Pain etc concepts into the current residency you are in. More years means more fiscal debt. Why are docs so bitter these days? Their debt to income ratio is growing. I do agree that CCM is a great field. However, the burden should be on the residency programs to include that in the residency.

People complain about the fact that we're not producing docs fast enough. Well how can we, when ppl are forced to be in training for longer and longer periods of times, again increasing their debt. Nurses on the other hand 'crank' out their own quickly and therefore gain ground.

 

[Stimulate]

not to seem harsh folks...but this "all it is is another year of education" bantering is quite ridiculous. yes, we are in medicine and we are ALL life long learners, but since when did we hear those words, "it's just a little more education". We've heard it in high school, then college, then med school, and now residency. ppl want to extend residency? Why not include CCM/Pain etc concepts into the current residency you are in. More years means more fiscal debt. Why are docs so bitter these days? Their debt to income ratio is growing. I do agree that CCM is a great field. However, the burden should be on the residency programs to include that in the residency.

People complain about the fact that we're not producing docs fast enough. Well how can we, when ppl are forced to be in training for longer and longer periods of times, again increasing their debt. Nurses on the other hand 'crank' out their own quickly and therefore gain ground.

I feel your pain on this issue but to address critical care and pain management. First, critical care is too broad of a discipline to become a competent practitioner by bolstering the CCM emphasis in a 4 year anesthesiology residency. Cleary the expert consensus (American Board of Anesthesiology and Internal Medicine) is that it takes between 5 and 6 years (I know surgeons can do CCM as well but I don't know the total time committment for that) to train an intensivist. An IM resident spends roughly 6 years (3 years IM/3 years Pulm/CCM if I am not mistaken), and an anesthesiologist does the same in a total of 5 years. In the next few years there is going to be an incredible demand for intensivists. Obviously I wouldn't do CCM unless I really enjoyed it, but it looks like a good career. Nurses cannot practice critical care so they aren't competing for those jobs. They can crank out all the CRNAs they want but you won't find them in the ICU.

Next, regarding pain management, also is too broad of a discipline to achieve any sort of expertise by bolstering emphasis in a 4 year anesthesiology curriculum. Pain management is a great specialty with huge demand, but the problem with Pain is the wide variety in quality and capability of practitioners out there. This stems from there being multiple pathways to become certified in PM. The ACGME is tackling this problem by increasing the multi-disciplinary focus of all existing fellowships, and also by potentially increasing the length of fellowship. By spending an extra year doing a pain fellowship (again you have to enjoy it, not just doing it for money) you can greatly expand the scope of services your anesthesia group can provide, and you can enter a field where CRNAs are not an issue.

So yes, I do get sick of hearing "it is just 1 more year" but looking back on your decisions to attend high school, college, medical school, residency, etc...these are necessary steps to get to an endpoint. Each person has to decide if that extra sacrifice is worth it to them. A fellowship salary and some locums work on the side can really reduce your opportunity cost while giving you many additional options in the future.

If we don't have enough trained physician providers to take care of critically-ill and pain patients, mid-level providers will become a necessity and jeopardize those fields as well.

 

[EtherMD]

The bottom line is this for those of you in training: You have come this far and all you need is ONE extra year to "hedge your bets" for the future. Please pick a subspecialty of Anesthesiology and do the extra 12 months. It will only make you a stronger Anesthesiologist and more prepared for the future.

There is NEVER a better time to do a fellowship than right after Residency.
JUST DO IT!

 

[rmd722]

Stimulate says...."Nurses cannot practice critical care so they aren't competing for those jobs. They can crank out all the CRNAs they want but you won't find them in the ICU".

Columbia University has an ICU for their transplant patients that is run by an all Advanced Practice Nurse team.

Several posts have eluded to the idea that the management of the toughest cases fall under the exclusive pervue of physicians. There is a new paradigm in health care being pushed forward by the nursing community that would educate these APN's to direct care for patient's with complex co-morbidities.

It is just a matter of time before APN's/CRNA's gain a greater foothold in the venues that you describe as sacred ground.

Just my 2 cents.

 

[SexPanther]

This is what irritates me and possibly many others. If you want to practice medicine, go to medical school. To be able to circumvent that route is a slap in the face of all of us who chose to undergo the rigors of med school + residency.

 

[Stimulate]

Stimulate says...."Nurses cannot practice critical care so they aren't competing for those jobs. They can crank out all the CRNAs they want but you won't find them in the ICU".

Columbia University has an ICU for their transplant patients that is run by an all Advanced Practice Nurse team.

Several posts have eluded to the idea that the management of the toughest cases fall under the exclusive pervue of physicians. There is a new paradigm in health care being pushed forward by the nursing community that would educate these APN's to direct care for patient's with complex co-morbidities.

It is just a matter of time before APN's/CRNA's gain a greater foothold in the venues that you describe as sacred ground.

Just my 2 cents.

We have Acute Care NPs at my institution but they work under the supervision/license of intensivists and must abide by a collaborative agreement between physician and NP.

I was unaware that in the state of NY, NPs are allowed to practice critical care medicine independently of and without collaboration with physicians.

So are these nurses licensed to interpret CXRs, place invasive lines, and legally make end of life decisions (withdrawing care, pronouncing patients dead, etc.) all without supervision?

You may want to consider reviewing this matter with the medical board in the state of New York, as this may be a serious violation of scope of practice.

Aside from New York, the intensivist and ANPs function in collaboration which is different than the issues with CRNAs and anesthesiologists. The CRNAs are cutting anesthesiologists out of the picture and are working under the license of the SURGEON or PROCEDURALIST. I would be very surprised if the standard of care in ICUs is going to evolve into having no intensivist involved, in favor of ANPs working under the license of the surgeon or proceduralist. This is precisely what groups like Leapfrog have successfully fought against.

 

[johankriek]

We have Acute Care NPs at my institution but they work under the supervision/license of intensivists and must abide by a collaborative agreement between physician and NP.

I was unaware that in the state of NY, NPs are allowed to practice critical care medicine independently of and without collaboration with physicians.

So are these nurses licensed to interpret CXRs, place invasive lines, and legally make end of life decisions (withdrawing care, pronouncing patients dead, etc.) all without supervision?

You may want to consider reviewing this matter with the medical board in the state of New York, as this may be a serious violation of scope of practice.

Aside from New York, the intensivist and ANPs function in collaboration which is different than the issues with CRNAs and anesthesiologists. The CRNAs are cutting anesthesiologists out of the picture and are working under the license of the SURGEON or PROCEDURALIST. I would be very surprised if the standard of care in ICUs is going to evolve into having no intensivist involved, in favor of ANPs working under the license of the surgeon or proceduralist. This is precisely what groups like Leapfrog have successfully fought against.

I heard there was a Nurse Practicioner doing open heart surgery in rural montana. She was only allowed to do bypasses and no complicated valves or anything like that.

 

[Stimulate]

I heard there was a Nurse Practicioner doing open heart surgery in rural montana. She was only allowed to do bypasses and no complicated valves or anything like that.

yeah those poor sheep

 

[johankriek]

there were no differences in outcome

 

[jwk]

I heard there was a Nurse Practicioner doing open heart surgery in rural montana. She was only allowed to do bypasses and no complicated valves or anything like that.

I'll call that what it is - BS - surely you don't believe this?

 

[VolatileAgent]

I hate to paint such a bleak picture of anesthesiology but everything is going to come down to money in the long run.

do you think this is a new concept? a lot of the issues that people are getting their panties in a bunch about have been brewing for a long time. in fact, the apex of this "crisis" could arguably have happened 7 years ago.

you need to worry more about pmc's. crna's issues are only a small portion of the problem. navigating the treacherous healthcare waters, they are nothing more than angry guppies in a pool of killer sharks.

 

[Stimulate]

there were no differences in outcome

both the control and the treatment flock died

 

[MacGyver]

You guys are really missing the point.

Every year the AANA publishes these studies (albeit in low quality journals) supposedly showing equivalent outcomes between MDAs and CRNAs.

Yet with all the MDAs out there and all the high quality gas journals available, I have not seen ONE study which shows that MDAs are in fact better than CRNAs. There's lots of crap out there about the ACT model vs MDA-only vs CRNA-only but there's no MDA-only vs CRNA-only comparison studies.

Tell your lazy academic colleagues to get off their ass and start figthing fire with fire. Until you have these studies, you are on a sinking ship.

 

[johankriek]

You guys are really missing the point.

Every year the AANA publishes these studies (albeit in low quality journals) supposedly showing equivalent outcomes between MDAs and CRNAs.

Yet with all the MDAs out there and all the high quality gas journals available, I have not seen ONE study which shows that MDAs are in fact better than CRNAs. There's lots of crap out there about the ACT model vs MDA-only vs CRNA-only but there's no MDA-only vs CRNA-only comparison studies.

Tell your lazy academic colleagues to get off their ass and start figthing fire with fire. Until you have these studies, you are on a sinking ship.

get lost you MURSE.. MALE NURSE.. go back to the nursing forums to call doctors lazy. You have some nerve.. I would censure you for that.
The reason why there are no studies that we have is because its common sense that physicians are better. Thats like doing a study that says driving with your arms versus your feet is better.. you dont need a study to tell you which is better.. so get lost..

 

[EtherMD]

get lost you MURSE.. MALE NURSE.. go back to the nursing forums to call doctors lazy. You have some nerve.. I would censure you for that.
The reason why there are no studies that we have is because its common sense that physicians are better. Thats like doing a study that says driving with your arms versus your feet is better.. you dont need a study to tell you which is better.. so get lost..

I was on www.aamessageboard.com a few months ago and read an interesting point: there is no hard data to show parachutes save lives!
In other words, we can not prove that jumping out of a plan at 5,000 feet without a prachute is "safer/better" than having one.

This is similar to the CRNA vs. MDA argument that nurses like to start.
CRNA's rarely do the tough ASA 4 cases alone. They stick with ASA 1 and ASA 2 cases solo and utilize MDA services for the difficult cases. The data is "skewed" and "faulty" because the acuity of the cases are not the same.
Who in their right mind would allow a CRNA to gather this data? The same guy who wants you to jump out of an airplance without a parachute at 5,000 feet.

You guys what to see what CRNA's think about MDA's privately? Check out that message board. Warning you must be at least 18 to read those posts.

 

[MacGyver]

So basically your strategy is to sit back and hope that some 50 year old balding Congressmen and state legislators understand the scientific merits of research and how to distinguish a research article from JAMA vs that from "Nursing Research?"

How has that plan been working for you so far?

I dont care if it seems obvious or not, until you have those research studies proving the CRNA crap is all lies, you are going to lose the war no matter what you do.

P.S. CRNA programs are starting to tout their ability to create "perioperative" practioners. Sounds an awful lot like the plan you wanted to use to distinguish yourselves from them.

 

[johankriek]

MURSE.. gth

 

[EtherMD]

MURSE.. gth

Johan,

Just more Nurses who really think they can do your job and for less.
They are bold end emblazened by the AANA. More junk studies are coming and soon. I doubt the lawyers will fully recognize the lack of quality; or, for that matter, even care.

If CRNA's do your job for less then why pay you MD $$$ for the Case?
This is CMS' (Centers for Medicare and Medicaid) feeling on the matter.
Once the private payers join in then basic anesthesia will be a nurses job because it will be CRNA income (actually lower).

One way or the other the days of "solo" MD Anesthesia are limited. The only question is When (not if) it occurs.

 

[rmd722]

Stimulate says..."I was unaware that in the state of NY, NPs are allowed to practice critical care medicine independently of and without collaboration with physicians".

I inquired further into the matter and found that these APN's are actually employed by the anesthesia department at CUMC. They do work with a "high degree of independence" directing the care of their transplant patients. APN's do operate by a different set of rules v. CRNA's in that they agree to collaborate with a physician and subsequently, are not directed. FYI: the APN's do read x-rays for line placement/pathology. They do not place central lines. End of life decisions are made in a "team" construct. APN's can not pronounce.

Furthermore, they are part of a study being conducted by the university comparing outcomes (I do not know the variables) of APN directed v. MD directed care. I'm going out to get my subscription my Nursing Research today.

This is just a concrete example of what EtherMD has eluded to. The lines of distinction between health care providers is becoming increasingly more blurry. It raises a host of ethical issues in my mind. Who are all of these different care givers, with their different credentials, making bed side decisions? Is there no Captain of the ship? Is there somebody that a patient can point to as the director of his/her care. Can this director possibly be in tune with all of the big and small issues for a population of ICU patients?

The other issue that comes to mind, that is more immdiately pressing, is the Gastroenterologists pushing for RN's being allowed to administer propofol. We have gastro guys, with whom we currently work with, ready to have their office nurses do the cases. It's absolutly crazy.

What I have learned in my short career is that big money always trumps best practice.

 

[Stimulate]

Our cardiothoracic surgical ICU (run by Anesthesia Division) trains acute care NPs to place central lines, intubations, art lines, and even swan-ganz catheters as long as an MD is in the immediate vicinity. We have had 2 cases of cannulation of the subclavian artery by the NPs, 1 with a MAC catheter, thus requiring surgical repair. This isn't to say that a resident or attending wouldn't make the same mistake but it is food for thought. Many of these errors are not being tracked or reported. I never want to hear anyone at my institution complaining about NPs/PAs because WE are training them. Their existence is a result of not enough attendings and residents to get all the work done. A couple of them have major attitudes which makes it all the more annoying that they exist.

I agree it all comes down to cost and not enough providers to care for the growing number of patients. The lines are going to continue to blur and studies looking for outcome differences are going to be hard to perform. The sample size would have to be huge to say the least, and also, the physicians are going to always be there to bail them out if they get in over their head because it is best for patients. There should be a way to correct for that in their research...i.e. a category comparing the number of instances where NPs had to consult an attending compared to number of instances where an attending had to consult an NP.

I have to admit some ignorance regarding the use of propofol by non-anesthesia trained providers (I don't know what the current regulations are). Maybe this has already happened but my guess is that CMS/insurers will severely cut reimbursement for anesthesia for endoscopy, or make a whole list of strict criteria that basically limits the number of cases where they will pay for anesthesia care. Cuts will continue until eventually the pay is so low for those cases that anesthesiologists will not do them and this will pave the way for RNs administering propofol in presence of a licensed physician. Finally, this will spawn a whole new field of "sedation RNs" that perform 20 intubations and then are allowed to do MAC cases.

So probably for people just heading into the field of anesthesiology it would be wise to find a way to "hedge your bets", i.e. find a niche where you can use your extra knowledge and training to distinguish yourself. Yes by being a physician you are already distinguished but these CEOs and politicians don't care. They want to cut spending on healthcare, and as long as there is no smoking gun that they arenjeopardizing patients they will continue to expand scope of practice for midlevel providers. Plus now midlevel providers are expanding their scope of practice through their own boards issuing "rulings" that can only be fought by the expensive litigation process.

I also think supporting your physician advocacy groups with contributions is wise because these groups get the message out to the politicians so that they don't actually believe what they see in Nursing Research (a subsidiary of "Skin Care Digest"?).

 

[Amgen1]

NEJM
Impact factor 44.0

ANESTHESIOLOGY
Impact factor 4.00

Nursing research
Impact factor 1.1

 

[MacGyver]

If you dont publish any studies comparing CRNAs vs MDAs, watch your autonomy and distinction from CRNAs continue to fade away into the sunset.

Personally I think hte AANA propaganda is BS. But you have to PROVE its bull**** or you dont have a leg to stand on.

You guys are losing the war with the AANA because for far too long you have been arrogant and always assumed that because you were doctors you would be treated on a higher level than CRNAs.

Is there not ONE study in the entire United States medical research literature that proves that MDA-directed care is better than CRNA-directed care? WTF have your academic attendings been doing for the past 20 years while the AANA has published study after study?