Patient ability to opt out of non-physician anesthesia

[Fiend]

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Are anesthesia providers required to notify patients of their general credentials before providing service (i.e. do they have to tell patients they are MDs/DOs, CRNA, or AAs?)
Also, do states allow patients to opt out of CRNA-administered anesthesia?
I want to know what rights as a potential patient (and for my family as well) that I have. There is such a huge push for a patient's bill of rights, but is this measure included.

 

[Tenesma]

the patient can decide who provides his care - and if the patient doesn't consent for CRNA care - unless it is a life/limb-threatening emergency, then that wish needs to be complied with.

 

[jwk]

Patient's can request it. However, in our department, they have to make that request known ahead of time - meaning several days ahead of time so we can plan our staffing accordingly. If they show up the morning of surgery wanting an MD to do their anesthesia, and have never made that preference known ahead of time to anyone, they will have to A) have an anesthetist or B) postpone their surgery. Not ideal, but that's the way it is.

 

[sean wilson]

I wonder how many people would go along with it if asked the following:

"We have a physician and a nurse, both of whom can give you anesthesia. Do you mind having the nurse do it?"

 

[jwk]

I wonder how many people would go along with it if asked the following:

"We have a physician and a nurse, both of whom can give you anesthesia. Do you mind having the nurse do it?"

Oh god, you didn't say "nurse" did you? 😱

And in all seriousness - any physician who would actually say that is a jerk.


"We have an anesthetist who does cases in the OR everyday, and a physician who does 3 cases a year (literally). Do you mind if the doc does the case?"

Does that sound better? I doubt it.

 

[Catfish John]

Oh god, you didn't say "nurse" did you? 😱

And in all seriousness - any physician who would actually say that is a jerk.


"We have an anesthetist who does cases in the OR everyday, and a physician who does 3 cases a year (literally). Do you mind if the doc does the case?"

Does that sound better? I doubt it.

He did say nurse, because an anesthetist IS a nurse. CRNA=nurse anesthetist....an advanced trained NURSE. Would you really introduce yourself as an "anesthetist" to a patient, not a "nurse anesthetist", knowing full well that most patients consider "anesthetist" a synonym for "anesthesiologist"?

 

[jwk]

He did say nurse, because an anesthetist IS a nurse. CRNA=nurse anesthetist....an advanced trained NURSE. Would you really introduce yourself as an "anesthetist" to a patient, not a "nurse anesthetist", knowing full well that most patients consider "anesthetist" a synonym for "anesthesiologist"?

Ah, you obviously haven't read some of the threads about the CRNA's resenting being referred to as nurses. It was a tongue-in-cheek response on my part. I certainly don't need a lesson about what the letters stand for, although obviously you do - CRNA=Certified Registered Nurse Anesthetist. And AA=Anesthesiologist Assistant, which is what I am.

I don't necessarily agree with your statement that most patients consider an anesthetist a synonym for anesthesiologist. In any event, most anesthetists that I know introduce themselves as a nurse anesthetist, an anesthesiologist assistant, or an anesthesia PA. And most anesthetists, myself included, are more than happy to define the difference for the patient, because many of them want to know. And most of the anesthesiologists in my department make it clear that an anesthetist, either CRNA or AA, will be with them during their procedure, which is exactly what they should be doing as part of the informed consent process.

 

[dbiddy808]

I'm an internal medicine resident who will be doing anesthesiology after finishing my medicine residency. I have only worked with CRNAs in the ICU setting where they (at least in my hospital) will do airway at night if we want them to. I'm shocked to hear that nurse anesthetists would introduce themselves as anything other than a nurse or nurse anesthetist. Its kind of misleading to introduce yourself as an anesthetist since most people would not be able to differentiate between anesthesiologist and anesthetist.

As a side-note...the other day I was sitting at a nursing station when a nurse went up to a perfusionist and called him Doctor so-and-so. He made no attempt to correct the nurse at all.

 

[jwk]

I'm shocked to hear that nurse anesthetists would introduce themselves as anything other than a nurse or nurse anesthetist. Its kind of misleading to introduce yourself as an anesthetist since most people would not be able to differentiate between anesthesiologist and anesthetist.

Be shocked all you want. And trust me - a CRNA will not introduce themselves as a nurse - only a nurse anesthetist. I think most nurse anesthetists and AA's introduce themselves appropriately, and as I stated in my previous post, are more than happy to explain the difference between the professions.

What is really misleading is the anesthesiologist who leads the patient to believe that THEY are PERSONALLY administering the anesthetic and staying with the patient, when it is an anesthetist who is actually doing the case. No mention of a CRNA or AA - no mention of the anesthesia care team mode of practice. In those cases, I would suggest that they are deliberately misleading the patient. I promise you this happens much more often than this ill-perceived notion that an anesthetist would deliberately mislead the patient into thinking that they are a physician.

 

[sean wilson]

"And trust me - a CRNA will not introduce themselves as a nurse - only a nurse anesthetist."

Correct. I had my shoulder surgery and the nurse came in and took over for the physician--all without anyone mentioning anything about the change.

For those who object to differentiating betwen nurse and physician on the basis that it hurts their credibilty, imagine how physicians think when a nurse complains about not being thought of in the same light as a doctor! Ironic, indeed.

Moral: Like the idea of being called (and respected as) a doctor? Go to medical school. Nothing unfair about it.

 

[undecided05]

kind of funny... the way you make it sound, anesthesiologists must be chillin on the 9th hole by the time they need to hall ass back to the hospital to greet the patient in post-op.

 

[gaseous]

Why is it that there is always so much arguing about CRNAs staying in the room during the procedure while the anesthesiologist doesn't?


Is this any different than the internist who rounds on the floor once a day then leaves while the floor nurse takes care of the patient....

Edit: Or the ICU. the same above situation occurs. I would also believe that Unit patients can be more challenging than most bread and butter anesthesia cases.

Food for thought.

 

[jwk]

Correct. I had my shoulder surgery and the nurse came in and took over for the physician--all without anyone mentioning anything about the change.

What probably happened was that the CRNA and MD both started your case and the MD left after induction. There was no "taking over" for the physician. It would be very unusual for the MD to put the patient to sleep by themselves, and only then be passed off to one of the anesthetists after everything was settled, unless that anesthetist was giving them a break or relieving them at the end of a shift.

Again - if you were not informed that this was the way this group or hospital practices anesthesia, then you were mislead ahead of time or don't remember / didn't pay attention to the discussion. Most of our patients, including physicians and their families, pay very little attention to our informed consent forms, which fully disclose that our group is comprised of MD's, AA's, and CRNA's working as a team to provide anesthesia care.

The Anesthesia Care Team concept, where a physician provides supervision / medical direction to anesthetists is fully supported by the ASA, and recognized by CMS and countless private insurors.

 

[dbiddy808]

Based on what I've read in these discussions, it seems that anesthesiologists and nurse anesthetists have a similar relationship to what an intenivist has with his nursing staff. The MD goes over the plan with the nurse, and the nurse carries it out. This is fine and well as far as I am concerned.

I also think it is fine that nurses get additional proceedural training and to become nurse anesthetists. I can see how a nurse anesthetist can do all of these proceedures and titrate medications to acheive hemodynamic/metabolic parameters independant of being directly supervised. As long as they have discussed the case with an MD who is near by in case there is an emergency.

The problem I see is that there seems to be a disconnect between being able to do proceedures, titrate meds and between being able to understand the magnitute and intricacies of patients preexisting medical problems and how these problems interplay with different variables during their proceedures. I just don't see how you could pull an ICU nurse out of the ICU, give them some proceedural training and expect them to become have this knowledge. I say this with a great deal of respect for ICU nurses, many of whom I have learned a great deal from. I work closely with ICU nurses and interact daily with them on teaching rounds. While many are very bright and participate in our rounds, they do not have the basic science background or the EBM-based knowledge we have. That is why we are doctors and they are nurses.

I just don't see how it can be safe for surgeons to do proceedures alone with nurse anesthetists. Especially in the surgicenter or out-patient setting. That sounds like a set-up for disaster. At least in the hospital setting, there is a code team with an intensivist, hospitalist or ER doctor.

Just my two cents.

 

[jwk]

Based on what I've read in these discussions, it seems that anesthesiologists and nurse anesthetists have a similar relationship to what an intenivist has with his nursing staff.

I also think it is fine that nurses get additional proceedural training and to become nurse anesthetists.

I just don't see how you could pull an ICU nurse out of the ICU, give them some proceedural training and expect them to become have this knowledge.

I just don't see how it can be safe for surgeons to do proceedures alone with nurse anesthetists. Especially in the surgicenter or out-patient setting. That sounds like a set-up for disaster. At least in the hospital setting, there is a code team with an intensivist, hospitalist or ER doctor.

Where are the CRNA's and why am I making their points for them? 🙂

1) Anesthesia school (CRNA or AA) is much more than "procedural training".

2) I think it's an entirely different relationship than an intensivist and RN.

3) You may not think it's safe, but it's done thousands of times every day. That being said, let me remind you I'm an AA and work ONLY within the anesthesia care team method of practice, which I personally think is the safest way of practicing.

4) Plenty of disasters happen IN hospitals WITH anesthesiologists around. Please don't pretend that only non-MD's have disasters.

5) It doesn't take an intensivist, a hospitalist, or an ER doc to run a code. Most "non-intensivist" anesthesiologist would take offense at that statement.

No offense, but you really need to get a better idea of what anesthetists do than what your own admittedly limited exposure to them suggests. They certainly do more than "do airway" in the ICU, which appears to be the full extent of your contact with them.

 

[dbiddy808]

Like I previously mentioned, I am an internal medicine resident have only limited exposure to CRNAs and the OR (except for when I was a med student). But.............I will once again give my two cents.

I realize that CRNA/AA training is more than proceedural, but I don't see how 2-3 years of training as an AA or CRNA can compare to that of a physician. Remember that by the time we set food in an anesthesiology residency program we have at least a bachelors degree, four years of intensive education as medical students and a year of internship. This is 9 years of education. And that is before setting foot in a residency program which is another 3 years of training.

And yes, I realize that complications occur regardless of who is delivering care, but this does not mean that we should not give patients the best possible chance of surviving these complications.

 

[sones]

Based on what I've read in these discussions, it seems that anesthesiologists and nurse anesthetists have a similar relationship to what an intenivist has with his nursing staff. The MD goes over the plan with the nurse, and the nurse carries it out. This is fine and well as far as I am concerned.

I also think it is fine that nurses get additional proceedural training and to become nurse anesthetists. I can see how a nurse anesthetist can do all of these proceedures and titrate medications to acheive hemodynamic/metabolic parameters independant of being directly supervised. As long as they have discussed the case with an MD who is near by in case there is an emergency.


The problem I see is that there seems to be a disconnect between being able to do proceedures, titrate meds and between being able to understand the magnitute and intricacies of patients preexisting medical problems and how these problems interplay with different variables during their proceedures. I just don't see how you could pull an ICU nurse out of the ICU, give them some proceedural training and expect them to become have this knowledge. I say this with a great deal of respect for ICU nurses, many of whom I have learned a great deal from. I work closely with ICU nurses and interact daily with them on teaching rounds. While many are very bright and participate in our rounds, they do not have the basic science background or the EBM-based knowledge we have. That is why we are doctors and they are nurses.

I just don't see how it can be safe for surgeons to do proceedures alone with nurse anesthetists. Especially in the surgicenter or out-patient setting. That sounds like a set-up for disaster. At least in the hospital setting, there is a code team with an intensivist, hospitalist or ER doctor.

Just my two cents.

Where have you been and who are y ou? The nurse anesthetist and anesthesiologist job is NOTHING like an intensivist/floor nurse relationship. As a floor nurse I was told what to do within certain parameters, the nurse anestetists I work with make their own decisions and MIGHT consult the anesthesiologist if they feel the need. The anesthesiologist is there for back up support more than to dictate the care that the patient receives. When was the last time you went to a code in the OR? We handle our own codes in the OR and the ED doc, intensivist, who the heck ever thinks they should show up never knows about it. For your information, the anesthesia on call person carries the code pager where I work!! And, I am not attending school for 3 additional years of school to learn PROCEDURES!! I have to take physiology, organic chemistry, and biochemistry, as well as a gross anatomy lab, pharmacology, and a ton of clinical hours. While I am no doc, and I"ll never pretend to be, I am not a gloried technician either!! ALso, i have yet to see one of our CRNAs call up a physician and specifically discuss the case they will be doing FOR them. And, if you're worried about the safety of nurse anesthetists, don't have anesthesia. You might be put to sleep by an AA or and CRNA. And, don't have a wreck anywhere in rural USA, you will be put to sleep by a CRNA WITHOUT an MD around. It happens all the time in the rural USA, might not be CABG or a crani, but it happens. CRNAs are not MDAs, you're absolutely right, but they are qualified anestheisa providers, not gloried technicians...and I'm so glad that's all the things that happen in the US healthcare system are "fine with"you. If I operated as a nurse anestetist the way you would have it, I would literally be an ICU nurse. Titrating gtts for patient hemodynamic stability is precisely what I did as an ICU nurse. And in that case I was in constant consultation with my physician. Have you ever met a nurse anesthetist?? Have you ever talked with an anesthesiololgist? Do you know the dynamics of this relationship when its a healthy one? OBVIOUSLYL NOT!!

 

[sones]

Like I previously mentioned, I am an internal medicine resident have only limited exposure to CRNAs and the OR (except for when I was a med student). But.............I will once again give my two cents.

I realize that CRNA/AA training is more than proceedural, but I don't see how 2-3 years of training as an AA or CRNA can compare to that of a physician. Remember that by the time we set food in an anesthesiology residency program we have at least a bachelors degree, four years of intensive education as medical students and a year of internship. This is 9 years of education. And that is before setting foot in a residency program which is another 3 years of training.

I understand we do not have the education of a physician. Do YOU realize that most nurse anesthetists have a bachelors degree....a year of required prerequisite science courses, 2 OR MORE years of experience IN DIRECT PATIENT CARE!!!!!! and then three years of OR experience!!!!! That's almost 9 years of experience as well. Not the same experience...but whos comparing?? I got my bachlors degree and then took several science classes PRIOR to starting my program. I work in the ICU/CCU for 2 years and then I did 2 years of Open Heart Recovery where my surgeon basically let us write the orders in the middle of the night and then he signed them in the morning. No it's not medical school, but its not whatever the hell you think our training is!!! I don't think may nurse anesthetists would pretend they did go to medical school, and if they do, they're in the wrong!! But, you better get a little more respect for advanced practice nurses and other mid-level practitioners, they exist and most provide high quality care to their patients. And what in the hell makes you think that a patient with a physician anesthsiologist has a bertter chance of making it than a patient who is cared for by a nurse anesthetist or an anesthesia assistant? I have been in rooms with anesthesiololgists who have extubated patients who were in respiratory distress...ON PURPOSE!!! She thought he would get better with the tube out...umm...except that he was in bronchospasm!!! Docs make mistakes too....you as a resident should know that better than anyone!!!!! 😱
GET A CLUE!! 😡

 

[jwk]

I also think it is fine that nurses get additional proceedural training and to become nurse anesthetists.

I realize that CRNA/AA training is more than proceedural,

Just quoting your own words - you said it, I didn't.

...but I don't see how 2-3 years of training as an AA or CRNA can compare to that of a physician.

No one on this thread has made that claim, and I fully disagree with the handful of CRNA's who claim they are the equals to anesthesiologists. I work within the anesthesia care team each and every day in one of the largest anesthesia groups in the U.S. None of the AA's or CRNA's in my group think we are the equals of our MD's, yet we all work together for the patient's benefit. All three groups bring a lot to the table. We all have strengths and weaknesses. Even within the anesthesia care team, we have a lot of freedom, and don't require step-by-step instruction or guidance. It's not necessary, nor is it required. And when an emergency arises, we will do whatever is necessary to protect/treat the patient (while awaiting help) whether that be resuscitation during an arrest or doing a crash C-Section when baby/mom are in trouble. And yes, those situations are perfectly allowable for us to manage within the anesthesia care team concepts as well as state and federal laws and regulations in all 50 states.

And yes, I realize that complications occur regardless of who is delivering care, but this does not mean that we should not give patients the best possible chance of surviving these complications.

There are no studies that show better outcomes with just anesthesiologists. The best studies to date show that an anesthesia care team arrangement provides the best outcomes. I agree 100% with sones - you have got to get some experience and first-hand knowledge working with anesthetists so you have a better understanding of their capabilities and training. Maybe if you continue on with an anesthesia residency you'll get that, maybe not.

 

[sean wilson]

"What probably happened was that the CRNA and MD both started your case and the MD left after induction. There was no "taking over" for the physician. It would be very unusual for the MD to put the patient to sleep by themselves, and only then be passed off to one of the anesthetists after everything was settled, unless that anesthetist was giving them a break or relieving them at the end of a shift."

No, I recounted the event correctly, thank you very much. MD did the block, nurse did the rest.

 

[champs]

To MDs: It is pointless to continue arguing with CRNAs and AAs. If you want to make a difference at all, then in the next few years become active in ASA and go to the conferences. It would also be wise to visit the Kerry website and read about his thoughts on removing the restrictions to practice for APRNs. This paragraph was on the Kerry website before a combined site was made for Kerry/Edwards:
"John Kerry will ensure fair treatment for Nurse Practitioners, Clinical Nurse Specialists, Nurse Midwives and Nurse Anesthetists. Numerous studies have shown that advanced practice nurses provide safe and high quality care. It is long past time that the federal government properly recognized the crucial role that APRNs play in the American health care system. John Kerry has supported legislation to expand reimbursement opportunities for APRNs. However, he understands that there is much more to do to end the discrimination and barriers to practice that APRNs face. Too often, APRN services are not reimbursed by third party payers. They aren't on panels that set reimbursement policy or assess care. Highly restrictive limitations on APRN scope of practice persist. These barriers deny health care consumers the widest possible choice of providers. As president, John Kerry will fight for specific legislative and regulatory changes to allow APRNs to practice fully. "

This is where you should be focusing your energies. Arguing within this forum will not guide the future of our profession, it will only irritate you. The people who throw out comments on this forum (originally intended for MDs to advise other MDs) are arguing about their status and qualifications because they are insecure about their level of training. Be proud of your accomplishments and help promote our profession via methods that will ACTUALLY have an impact. If you want to voice your opinion here too, then fine, but make sure to offer your thoughts where it will truly do some good!!

 

[sones]

To MDs: It is pointless to continue arguing with CRNAs and AAs. If you want to make a difference at all, then in the next few years become active in ASA and go to the conferences. It would also be wise to visit the Kerry website and read about his thoughts on removing the restrictions to practice for APRNs. This paragraph was on the Kerry website before a combined site was made for Kerry/Edwards:
"John Kerry will ensure fair treatment for Nurse Practitioners, Clinical Nurse Specialists, Nurse Midwives and Nurse Anesthetists. Numerous studies have shown that advanced practice nurses provide safe and high quality care. It is long past time that the federal government properly recognized the crucial role that APRNs play in the American health care system. John Kerry has supported legislation to expand reimbursement opportunities for APRNs. However, he understands that there is much more to do to end the discrimination and barriers to practice that APRNs face. Too often, APRN services are not reimbursed by third party payers. They aren't on panels that set reimbursement policy or assess care. Highly restrictive limitations on APRN scope of practice persist. These barriers deny health care consumers the widest possible choice of providers. As president, John Kerry will fight for specific legislative and regulatory changes to allow APRNs to practice fully. "

This is where you should be focusing your energies. Arguing within this forum will not guide the future of our profession, it will only irritate you. The people who throw out comments on this forum (originally intended for MDs to advise other MDs) are arguing about their status and qualifications because they are insecure about their level of training. Be proud of your accomplishments and help promote our profession via methods that will ACTUALLY have an impact. If you want to voice your opinion here too, then fine, but make sure to offer your thoughts where it will truly do some good!!

Ok, since this website is for us to discuss anesthesia related topics, tell me, why do you MDAs feel threatened by CRNAs and AAs? Constructively, what would make the working relationship better from your standpoint? You're not going to drive midlevel providers out, there is too much need. So, what can be done to stop the stone throwing and to get something constructive done? Obviously nothing is getting done at this point.

 

[ether_screen]

Every time that I read these posts, I have to remind myself that many of these people don?t have a clue what it is like in the real world between MDAs, CRNAs, and AAs; or, they simply choose to ignore it and propagate this war from the safety of their home computers. Many who participate in this forum operate under the false assumption that only physicians can think critically and make the appropriate judgments pertaining to patient care. This is simply not the case. Just examine the safety records of midlevel providers in anesthesia. I guarantee that for every one CRNA or AA fowl up, you can quite easily match it with at least one physician lapse in judgment. From this standpoint, one could make the argument that those extra years didn?t make much a difference. I think the bottom line is that that there are bad apples in every group regardless of their degrees held. Moreover, look towards other areas where physical therapists are acquiring privileges once only given to physicians, or dentists and optometrists moving in similar directions. Health care is an ever-evolving landscape, only those that learn how to adapt will thrive.

 

[undecided05]

Can't everyone just go off and be satisfied with what they do (of course not)... and have the self-esteem to not care what others think about them or how wonderful or lack there of and just end this here and now. This is just silly. Just sit back at your computer and smile.

And someone asked why medical students or residents/attendings are making a big deal, maybe because like all other American's these medical students and residents/attendings want to see the fruits of their labour. Paying lots of $$$ for education, sacrificing many hours and other opportunities, these people want to be shown the $$$ and even a little respect, but in my years on this earth I think people are willing to sacrifice the latter for the former... It's that simple. Whether right or wrong. Agree or disagree... I don't care. This type of thread is just lame.

 

[sones]

Can't everyone just go off and be satisfied with what they do (of course not)... and have the self-esteem to not care what others think about them or how wonderful or lack there of and just end this here and now. This is just silly. Just sit back at your computer and smile.

And someone asked why medical students or residents/attendings are making a big deal, maybe because like all other American's these medical students and residents/attendings want to see the fruits of their labour. Paying lots of $$$ for education, sacrificing many hours and other opportunities, these people want to be shown the $$$ and even a little respect, but in my years on this earth I think people are willing to sacrifice the latter for the former... It's that simple. Whether right or wrong. Agree or disagree... I don't care. This type of thread is just lame.

Two things to add...why participate if you think it's lame....and don't you think other healthcare professionals want the same things as the residents/doctors/medical students? Money and respect. Interesting, intersesting.......

 

[champs]

Not one place in that post was there a comment about ridding the world of midlevel practitioners. The post was made to those MDs arguing that there are better venues to discuss QUALIFICATION AND LEVEL OF TRAINING, and to discuss the issues related to Anesthesiologists. The post was addressed to MDs, from another MD. This forum is under the heading: "Graduate Medical Forums [MD/DO]." This is a place for MDs to discuss their field, learn more about it's current status and it's advancement, and learn how to obtain a residency within the specific field. There is a section on this site titled, "Healthcare Professionals Forum." There are headings there for RN, NP, PA etc. Argue your point there and let MDs discuss their professions here, whether you agree with the comments are not. Why do you feel the need to correct what you believe to be wrong by running around this site and posting replies? I don't attempt to know the intricacies of nursing or other midlevel training, and thus I don't troll around other sites pretending that I do. I am suggesting to my colleagues that they further educate themselves, and discuss these matters where they will have an effect, whether I AGREE WITH THEIR OPINIONS OR NOT. I don't have a problem with CRNAs, but I don't feel the need to explain that to you. What I do have a problem with are people who feel the need to constantly assert their intelligence and capability on this site, there is something wrong when you feel the need to do so. I only hope to have discussions with med students and residents, offer info on current issues, and ask for advice from other MDs who have shared the same path as me and truly understand my concerns.

 

[sones]

Not one place in that post was there a comment about ridding the world of midlevel practitioners. The post was made to those MDs arguing that there are better venues to discuss QUALIFICATION AND LEVEL OF TRAINING, and to discuss the issues related to Anesthesiologists. The post was addressed to MDs, from another MD. This forum is under the heading: "Graduate Medical Forums [MD/DO]." This is a place for MDs to discuss their field, learn more about it's current status and it's advancement, and learn how to obtain a residency within the specific field. There is a section on this site titled, "Healthcare Professionals Forum." There are headings there for RN, NP, PA etc. Argue your point there and let MDs discuss their professions here, whether you agree with the comments are not. Why do you feel the need to correct what you believe to be wrong by running around this site and posting replies? I don't attempt to know the intricacies of nursing or other midlevel training, and thus I don't troll around other sites pretending that I do. I am suggesting to my colleagues that they further educate themselves, and discuss these matters where they will have an effect, whether I AGREE WITH THEIR OPINIONS OR NOT. I don't have a problem with CRNAs, but I don't feel the need to explain that to you. What I do have a problem with are people who feel the need to constantly assert their intelligence and capability on this site, there is something wrong when you feel the need to do so. I only hope to have discussions with med students and residents, offer info on current issues, and ask for advice from other MDs who have shared the same path as me and truly understand my concerns.

I dont believe I ever accused you or anyone else of wanting to rid the world of midlevel practitioners. As for discussing the professional, medical aspects of anesthesiology here in this forum, I see less of that from the MDs and more midlevel bashing and questioning. And since when did anyone on this board suggest they know about the intricacies of medicine with being and MD? I never pretended be an MD or to know about the intricacies of your profession. I'm simply attempting to defend my own. And, as for the the forums, there is one for Nursing NP & RN. CRNAs are not necessarily addressed there and MDs do "troll" that very forum. AND, I do not think anyone was trying to assert their intellingence or capability, I believe the post was directed at a resident who knows nothing about the field of nurse anesthesia. Maybe you could read his post and tell me if that is your experience with nurse anesthetists? If it is, I'm sorry, You're not in a very good working situation then. I'm glad you have no problem with CRNAs. And again I ask, if you don't like what is being said, why are you reading the post and responding to it....as you have again!!!!! There are other discussions occurring here on YOUR anesthesiology forum, or are you just interested in this discussion as I think most who read this are?

 

[jwk]

To MDs: It is pointless to continue arguing with CRNAs and AAs. If you want to make a difference at all, then in the next few years become active in ASA and go to the conferences.

...The people who throw out comments on this forum (originally intended for MDs to advise other MDs) are arguing about their status and qualifications because they are insecure about their level of training...

First, let me quote from the SDN Forums Usage guidelines - "The Student Doctor Network is dedicated to developing and maintaining a friendly online community, where members of all ages and backgrounds feel relaxed and comfortable." There is nothing in the guidelines or Terms of Service that restrict posting across specialties or professions. There is nothing there that says "originally intended for MDs to advise other MDs".

Second, I am a member of the ASA, as well as the GSA (Georgia), and I DO go to their meetings. I am not arguing my status and qualifications - I know what they are and am very comfortable with them, and after more than 25 years in anesthesia, trust me, I am hardly insecure.

Third, anesthesia is a somewhat different specialty than most, in that more than one type of provider is legally able to provide services to the patient. Several of the posters in this thread appear to have limited exposure or knowledge of AA's and CRNA's, so several of us jumped in to offer our 2 cents worth.

I'm sure that the CRNA's in these threads have very differing views than I do as an AA, and physicians have yet another set of ideas, but we all have a right to our point of view and to express it. That's what I thought these forums were for. I'm sure if there is a discussion about life as a resident that I would have no interest in participating in that discussion, just as I have zero interest in the dermatology or podiatry forums. But anesthesia is my career, and when I feel I can contribute something to either a clinical discussion or one regarding non-physician anesthesia providers, I am perfectly willing to offer my point of view. My comments are not intended to start an argument, and I certainly don't feel that it's "pointless to continue arguing with CRNAs and AAs."

 

[sones]

First, let me quote from the SDN Forums Usage guidelines - "The Student Doctor Network is dedicated to developing and maintaining a friendly online community, where members of all ages and backgrounds feel relaxed and comfortable." There is nothing in the guidelines or Terms of Service that restrict posting across specialties or professions. There is nothing there that says "originally intended for MDs to advise other MDs".

Second, I am a member of the ASA, as well as the GSA (Georgia), and I DO go to their meetings. I am not arguing my status and qualifications - I know what they are and am very comfortable with them, and after more than 25 years in anesthesia, trust me, I am hardly insecure.

Third, anesthesia is a somewhat different specialty than most, in that more than one type of provider is legally able to provide services to the patient. Several of the posters in this thread appear to have limited exposure or knowledge of AA's and CRNA's, so several of us jumped in to offer our 2 cents worth.

I'm sure that the CRNA's in these threads have very differing views than I do as an AA, and physicians have yet another set of ideas, but we all have a right to our point of view and to express it. That's what I thought these forums were for. I'm sure if there is a discussion about life as a resident that I would have no interest in participating in that discussion, just as I have zero interest in the dermatology or podiatry forums. But anesthesia is my career, and when I feel I can contribute something to either a clinical discussion or one regarding non-physician anesthesia providers, I am perfectly willing to offer my point of view. My comments are not intended to start an argument, and I certainly don't feel that it's "pointless to continue arguing with CRNAs and AAs."

Thank you Jwk...you are much more eloquent than I.

 

[dbiddy808]

Like I mentioned earlier, I don't see CRNAs (or AAs for that matter, although I don't eally know what an AA is) as a bad thing.

I just don't see how giving ICU nurses an extra couple of years of training can make them into attending anesthesiologists, which is essentially what they are now since they are free to practice without MD supervision.

Sorry if it is insulting to the mid-levels out there.

 

[timtye78]

As I scroll through these posts, the tone is b/c more and more shrill.

We can go round and round debating on who is and isn't capable of pt care.
The system under debate is a mute point, similar to FP docs and their PAs.
The current care system is under pressure from many angles. Cost containment and the hardcore demand for anesthesia care is incredible! There was a time when the surgeons started anesthesia, had "nurses" maintain while they operated! Hey! Now at least they are RNs from competitive backgrounds, with intensive anesthesia training. I am an Anesthesiology Intern, and even when I b/c a CA-1, will hesitate to go into an OR with a CRNA and pretend to know more about anesthesiology than these guys!

As far as pt care is concerned, everything should be done under ideal terms. Now we all know that there are differences and variations obviously in Pt care, and/or patient informed consent. I am sure the hospital's legal counsel has worded the forms very well, so if you ever had the inclination, most forms I have seen have something like procedure "will be performed by Dr. X and/or associates." Some forms go farther as include medical students, residents etc. Pts should read what they sign or ask questions. Simple. I would venture to say that anesthesiologists ideally would be better if they explained the supervisory relationship with the CRNA/AA better. Whether or not the MD/DO decides to stick around closely or not depends on his/her comfort level, and will ultimately still be legally liable for mishaps. I don't think either way vastly changes the level of pt care assuming you have a well-trained CRNA/AA.

CRNAs and PAs and I guess AAs (no personal experience with these myself) are most likely a permanent addition to the healthcare team. Physicians can either utilize these people or not utilize these people, the same goes for patients.

My two cents 😎

 

[soon2bdoc2003]

how about this one.. would you rather have a crna with 10 years of experience providing your care or a brand new ca-1 fumbling around with a miller blade while your sats drop into the 70's. I really dont understand this crna vs. mda crap.. in my department we all pretty much work as a team and everyone knows their place in the OR. We have crna's to provide night shift relief which means at least some sleep on call and during the day they provide some relief from the endless stream of mac cases. The only complaint I have about crna's that some of them are pretty lazy, but that is to be expected from any nurse with 15-20 years of work under their belt.

We just finished up our first 2 months of "clinical uselessness" where we have been supervised by seniors, attendings or crna's all the time and I learned tons from everyone I worked with. As far as competing for jobs, at my hospital they are projecting and IMPOSSIBLE demand for both attendings and nurses for at least the next 5+ years. In the real world outside the university setting anesthesia means 1 thing to any practice and thats easy $$$. Private practice runs at an EXTREME pace and I for one would love to have a crna or aa at my side even if it means a cut in pay ($350k vs $500k 🙂 )

 

[HomerSimpson]

Wasn't Clinton a big fan of CRNA's? I mean wasn't his Mom a CRNA? And he is the one who attempted to change CRNA practice parameters? I wonder who is doing the anesthesia for his bypass? hmmmm Is it an anesthesiologist or a CRNA? DO you think a CRNA would even be in the room at all? I'm not saying that it wouldn't happen, and I honestly hope he does well, but the chances are slim that anyone without an MD(probably with a sign that says "Head of.." or "Chairman" on his coat) is going to be within 100 feet of that OR. But that the elitism and hypocracy of the democratic party showing its head.

Anyway, I am trying not to bash mid-level practitioners. If things stay where they are then that is fine. But your well paid leadership and the armies of lobbyists that you have in washington and other centers of government are attempting to change things so mid-levels would be equal to doctors. except for when THEY get their surgery of course. Then THEY need an expert. The fact is that if all of the anesthesiologists disappeared tomorrow, and you guys had free reign, anesthesia would not be considered a medical science, but a clinical skill like respiratory therapy and nursing. If that happened all of the great research that mostly MD's have started which has given you agents like sevoflurane and propofol at least in the US is gone.

Next I think that nurses have the misconception that they will be paid equal to an anesthesiologist if they get independent practice. well, say goodbye to that. If anesthesiology turns into the practice of nursing, then medicare will not reimburse you for your cases anymore, and neither will insurance. You don't think so? Look a wound care. That is a nursing practice that takes extra training. They do procedureal work on chronic wounds e.g. fitting vacs. Do you think they get paid well? no... The only reason we are paid well is because the boys and girls in washington see this specialty as a medical specialty. If it is a nursing specialty you will be paid similar to other advanced nurse practitioners. 60-100k rather than current figures. By the way my salary would drop severely as well so at least you guys get something out of it. THAT is how washington is gonna save money. do you really believe they are gonna save money by paying CRNA's the same as an anesthesiologist? how does that math work?

Why don't we just work together. try to keep reimbursement high and live well? because your leadership is not looking at the big picture. just their own very large egos are driving this. I know I am being a jerk here but I am personally sick of this debate.

 

[ultraconsrvativ]

The people who throw out comments on this forum (originally intended for MDs to advise other MDs) are arguing about their status and qualifications because they are insecure about their level of training.

The frustration of the MDA is similar to what the RN used to experience. I'm reminded of how RNs felt 15 years ago when hospitals decided 80% of their work could be done safely by an LPN and the hospital could realize lower labor costs. They would only need an "overseer" RN to direct the LPN. The RN was needed mainly in the more challenging ICU setting. The RN was in a sense overqualified and it was considered overutilization to use RNs to do the majority of easy nursing care on the hospital floor.
MDAs are essentially overqualified for the majority of the anesthesia cases and should be utilized more efficiently for the more difficult and complex cases. CRNAs and AAs are able to safely provide most of the care. Unlike the RN/LPN situation, use of AAs and CRNAs for the easy stuff in place of MDAs does not result in lower labor costs.

 

[jwk]

Unlike the RN/LPN situation, use of AAs and CRNAs for the easy stuff in place of MDAs does not result in lower labor costs.

That's because 1) the demand is still high for qualified anesthesia providers, MD or otherwise and 2) AA's and CRNA's are not just there for "the easy stuff". Maybe in some areas they only do "bread and butter" cases, but in many others they do ALL the cases, even with anesthesiologists around.

 

[guanaco]

that the idea of someone with less training doing my job is not very appealing. Maybe I am an ass or just a selfish person but I would make it a point to let a CRNA/AA know that they are not welcomed on my turf. What's the limit on the scope of practice for these people? Are all cases open to them or is there limits on what they can't do? I think something must be done before they receive a "carte blanche" from the crooked state legislators who apparently have decided that these people are allowed to play doctor without the proper training.

 

[Gator05]

The frustration of the MDA is similar to what the RN used to experience. I'm reminded of how RNs felt 15 years ago when hospitals decided 80% of their work could be done safely by an LPN and the hospital could realize lower labor costs. They would only need an "overseer" RN to direct the LPN. The RN was needed mainly in the more challenging ICU setting. The RN was in a sense overqualified and it was considered overutilization to use RNs to do the majority of easy nursing care on the hospital floor.
MDAs are essentially overqualified for the majority of the anesthesia cases and should be utilized more efficiently for the more difficult and complex cases. CRNAs and AAs are able to safely provide most of the care. Unlike the RN/LPN situation, use of AAs and CRNAs for the easy stuff in place of MDAs does not result in lower labor costs.

That's a VERY interesting observation. On the floors, when a patient really needed something (and needed to make sure it was done properly), I would find the RN. That's not to say there aren't good LPN's out there, it's just a matter of quality control. I've yet to see an LPN in a critical-care type role (I could easily be naive about this). And finally, perhaps there is some relation between the demise of the RN and medical errors?

I bet a well-trained CRNA could fulfill the role of the go-to person; it's just that the MDA has the opportunity to be better positioned for this role via their lengthened training.

 

[ultraconsrvativ]

That's a VERY interesting observation. On the floors, when a patient really needed something (and needed to make sure it was done properly), I would find the RN. That's not to say there aren't good LPN's out there, it's just a matter of quality control. I've yet to see an LPN in a critical-care type role (I could easily be naive about this). And finally, perhaps there is some relation between the demise of the RN and medical errors?

I bet a well-trained CRNA could fulfill the role of the go-to person; it's just that the MDA has the opportunity to be better positioned for this role via their lengthened training.

I agree.

 

[jwk]

that the idea of someone with less training doing my job is not very appealing. Maybe I am an ass or just a selfish person but I would make it a point to let a CRNA/AA know that they are not welcomed on my turf. What's the limit on the scope of practice for these people? Are all cases open to them or is there limits on what they can't do? I think something must be done before they receive a "carte blanche" from the crooked state legislators who apparently have decided that these people are allowed to play doctor without the proper training.

So what is "your job" and "your turf" ? Your profile is empty.

And since you are obviously totally clueless about CRNA's and AA's, why would you say they are not welcome when you have absolutely no idea what you're talking about?

"These people" have a fairly wide scope of practice, depending on state law and locale. You will find anesthetists in many major hospitals doing open hearts, neuro, trauma, peds, OB, etc., etc. For example - AA's in Georgia have a job description on file with the state outlining what they may do within that particular practice. Many AA's (and CRNA's) perform regional anesthetics and blocks, place central lines and PA catheters, and can be utilized in virtually all surgical sub-specialties. You will find CRNA's and/or AA's in most hospitals throughout the U.S. In about 15 states, CRNA's may practice independently of physicians. AA's practice within the anesthesia care team with anesthesiologists.

 

[guanaco]

So what is "your job" and "your turf" ? Your profile is empty.

And since you are obviously totally clueless about CRNA's and AA's, why would you say they are not welcome when you have absolutely no idea what you're talking about?

"These people" have a fairly wide scope of practice, depending on state law and locale. You will find anesthetists in many major hospitals doing open hearts, neuro, trauma, peds, OB, etc., etc. For example - AA's in Georgia have a job description on file with the state outlining what they may do within that particular practice. Many AA's (and CRNA's) perform regional anesthetics and blocks, place central lines and PA catheters, and can be utilized in virtually all surgical sub-specialties. You will find CRNA's and/or AA's in most hospitals throughout the U.S. In about 15 states, CRNA's may practice independently of physicians. AA's practice within the anesthesia care team with anesthesiologists.

I am a 4th year if that helps. How about you?
I think we should bring foreign MDs from india or elsewhere to fill the need instead of having nurses do a job that should really be done by a doctor.
Also, I bet they want to play doctor and they don't pay the same amount in malpractice insurance that an MDA pays. I understand that these folks work under an MDA's supervision so if something goes wrong, who gets sued? I am sure it'd be the supervising doc. Who in their right mind would want to take the responsability if one of these "doctor-wannabes" f*cks up?

 

[jwk]

I am a 4th year if that helps. How about you?
I think we should bring foreign MDs from india or elsewhere to fill the need instead of having nurses do a job that should really be done by a doctor.
Also, I bet they want to play doctor and they don't pay the same amount in malpractice insurance that an MDA pays. I understand that these folks work under an MDA's supervision so if something goes wrong, who gets sued? I am sure it'd be the supervising doc. Who in their right mind would want to take the responsability if one of these "doctor-wannabes" f*cks up?

Boy, you've got a lot to learn. You truly have no idea what you're talking about.

 

[TofuBalls]

Posting against my better judgement...

Reading the ASA Newsletter this August left me a bit irritated and dissapointed in my home state of LA. 🙁

http://www.asahq.org/Newsletters/2004/08_04/stateBeat08_04.html

Perhaps some of the AA's in the forum can comment on current practice opportunities in light of these AANA guerrilla tactics. I think this ultimately limits choice for all but one group.

 

[jwk]

Posting against my better judgement...

Reading the ASA Newsletter this August left me a bit irritated and dissapointed in my home state of LA. 🙁

http://www.asahq.org/Newsletters/2004/08_04/stateBeat08_04.html

Perhaps some of the AA's in the forum can comment on current practice opportunities in light of these AANA guerrilla tactics. I think this ultimately limits choice for all but one group.

AA's have been fighting this battle for the entire time we've been in practice - more than 30 years. Guerilla tactics is a good way of putting it.

Louisiana is the first state 👎 to actually prohibit a specific medical profession from practicing. Never mind that AA's were unable to be licensed there in the first place and could not practice there. It was an entirely self-serving piece of legislation proposed by the LANA and AANA - it's sole purpose is to attempt to deny AA's the opportunity to practice in Louisiana. it doesn't enhance patient care, it doesn't solve any problems. And if you read the language of the bill, it's essentially an editorial about the wonders of nurse anesthesia practice.

A bill to allow AA practice in Louisiana made it out of committee this year, but did not come up for a vote on the floor of the legislature.

Oh well, as with any piece of legislation, it can be turned around in subsequent years.

 

[conservative]

Boy, you've got a lot to learn. You truly have no idea what you're talking about.

What an understatement.

 

[conservative]

AA's have been fighting this battle for the entire time we've been in practice - more than 30 years. Guerilla tactics is a good way of putting it.

Louisiana is the first state 👎 to actually prohibit a specific medical profession from practicing. Never mind that AA's were unable to be licensed there in the first place and could not practice there. It was an entirely self-serving piece of legislation proposed by the LANA and AANA - it's sole purpose is to attempt to deny AA's the opportunity to practice in Louisiana. it doesn't enhance patient care, it doesn't solve any problems. And if you read the language of the bill, it's essentially an editorial about the wonders of nurse anesthesia practice.

A bill to allow AA practice in Louisiana made it out of committee this year, but did not come up for a vote on the floor of the legislature.

Oh well, as with any piece of legislation, it can be turned around in subsequent years.

The Governor is a democrat. Do I need to say more?

 

[guanaco]

Boy, you've got a lot to learn. You truly have no idea what you're talking about.

Is that the best you can do? First , you did not answer my question when I asked what your title is. Second, why don't you go ahead and explain what exactly the arrangement is between MDAs and CRNAs/AAs? Very easy to just blow someone off by saying they have no idea what one is talking about and yet provide no explanation/proof to the contrary. So go ahead and explain why I am wrong in assuming that CRNAs malpractice insurance (where they are allowed to work independently) is less and to also assume that an MDA would be held liable if a CRNA under his/her supervision screws up.
Go ahead and show me, Nurse!

 

[thegasman]

He's not a nurse, he's an aa. Why don't you read his profile. His profession practices only with anesthesiologists while crna's in many areas are lobbying and getting their own independent practice rights.

 

[guanaco]

He's not a nurse, he's an aa. Why don't you read his profile. His profession practices only with anesthesiologists while crna's in many areas are lobbying and getting their own independent practice rights.

OK so he is an AA. I was not aware. My bad. So he wouldn't know about paying malpractice insurance since he works under an MDA. But then what about the CRNAs who are allowed to work on their own. How do the malpractice rates compare? It is my hope that the insurance companies take notice so that they are charged the same as an MDA.

 

[jwk]

He's not a nurse, he's an aa. Why don't you read his profile. His profession practices only with anesthesiologists while crna's in many areas are lobbying and getting their own independent practice rights.

🙂

 

[jwk]

OK so he is an AA. I was not aware. My bad. So he wouldn't know about paying malpractice insurance since he works under an MDA. But then what about the CRNAs who are allowed to work on their own. How do the malpractice rates compare? It is my hope that the insurance companies take notice so that they are charged the same as an MDA.

We do pay malpractice - of course it's less than the MD. You'll have to find out from a CRNA about their's - I don't know.

It simply isn't possible for MD's to do every anesthetic in this country. There aren't enough numbers.

As for the rest of your ravings, they deserve little further comment. The MDA vs CRNA and/or AA debate has been worn out in several threads in this forum. Do a search of the threads and educate yourself. I don't feel like doing it for you.