Residency Hours

[pgg]

I was speaking more about military anesthesia than civilian. Talk to the military residents about how things are going. The last CABG I did before leaving internship, a CRNA was running it. Think the residents didn't need/want that case?

Last time I was at NNMC, as an intern 2002-2003 my perception was that there was a very ... unhealthy ... relationship between CRNAs and anesthesiologists. Very adversarial, with a lot of gunning and outright malicious sabatoge behavior from SRNAs toward residents.

It's the main reason why I ranked NNMC last when I applied for residency. I nearly didn't rank it at all.

Can't speak for NMCSD, but at Portsmouth I've never felt like I've lost a case or procedure to a SRNA, and on the whole we have very good relations with CRNAs and SRNAs. The resident always has priority over the SRNA.

'Mainly' is not always, and it's very simple to study CRNAs that practice without supervision (especially in other countries where that's much more common) to see if they have different outcomes. In fact both of the studies I linked reference unsupervised CRNA care. The study that found no statistical difference in results also found no difference for unsupervised CRNAs vs Docs.

One of the studies you linked was a bit of fluff from a nursing journal which compared obstetric services only between different hospitals, ignoring demographic differences in patient populations between those hospitals. This is garbage that ought to be laughed out of any journal club, were the organizers silly enough to include it in the first place. Totally apart from the design problems, there's the issue of publication bias, which I'd argue is not a small thing for some random nursing journal. (We're not talking Anesthesiology or Cell or even Newsweek here.)

Even comparing "unsupervised" CRNA care to anesthesiologist care within the same hospital isn't a simple prospect. At most military hospitals, CRNAs are essentially unsupervised for ASA 1 & 2 cases (healthy patients). If you compare their outcomes to those of anesthesiologists, whose patient load necessarily leans toward the sick, of course they'll be reassuring. This wouldn't be evidence that as a group they're capable of delivering equal care to all comers, though.

Finally, there's more to delivering an anesthetic than not killing the patient. There are no good studies about unplanned admissions or the necessity of postop interventions for pain, nausea, blood pressure control, etc. Ask any anesthesia resident suffering through a PACU month which group's patients make up the lion's share of pages for handling one issue or another (and this despite one group getting sicker patients and bigger cases than the other).

Um, no. The studies were quite large in scale, I have no idea how many others are out there (I'm not exactly writing a research paper here)

Heh. You found the ones that are always cited. Both of 'em. That's how "well" this issue has been studied.

It's been said before on the anesthesiology forum, but this will never be studied appropriately. To do so, you'd have to randomize all comers to "doctor care" or "nurse care" ... and nobody's going to give informed consent for that, especially if they're sick. Some would argue that even proposing this study is unethical.

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[Perrotfish]

Originally Posted by pgg
It's been said before on the anesthesiology forum, but this will never be studied appropriately. To do so, you'd have to randomize all comers to "doctor care" or "nurse care" ... and nobody's going to give informed consent for that, especially if they're sick. Some would argue that even proposing this study is unethical.

Well... that doesn't leave a whole lot of options for CRNAs arguing for their right to practice. I could see how they would push back against that. Anyway I don't see why this couldn't be done like a drug trial: give the people participating in the trial free healthcare and maybe some money on top of that. It's not like the national nursing organizations don't have the money. It doesn't seem significantly more unethical than pharm trials, either.

 

[pgg]

Well... that doesn't leave a whole lot of options for CRNAs arguing for their right to practice.

Sure it does! If they want to practice medicine, they can go to medical school. There's an important, respected, and safe place for CRNAs to practice within the ACT model.

 

[BigNavyPedsGuy]

Anyway I don't see why this couldn't be done like a drug trial: give the people participating in the trial free healthcare and maybe some money on top of that.

This isn't a drug trial!! You're talking about people's surgeries! The only way to accurately study this is use actual patients. How are you going to sell "you'll get a trial of free healthcare to see who can sedate you for your surgery with the least complications"?? People seldom look for the discount section when they let another human cut them open.

That is terrifying that you are even considering this.

 

[DrMetal]

This isn't a drug trial!! You're talking about people's surgeries! The only way to accurately study this is use actual patients. How are you going to sell "you'll get a trial of free healthcare to see who can sedate you for your surgery with the least complications"?? People seldom look for the discount section when they let another human cut them open.

That is terrifying that you are even considering this.

well then, how do experimental surgical procedures eventually gain FDA approval? There has to be some sort of 'clinical trial', right? where a certain pt pool receives the experimental procedure, while another gets the standard procedure. Of course the disclosure might be different, so it's not completely like a drug trial, where a pt may not know that he/she is getting a placebo.

so i think what pfish is suggesting is a study, where a certain pt pool is presided over by a CRNA indepentendly (or quasi-independently, with an anes standing by) . . .then another pool the standar way (by just an Anes), then compare the two, right?

 

[Perrotfish]

well then, how do experimental surgical procedures eventually gain FDA approval? There has to be some sort of 'clinical trial', right? where a certain pt pool receives the experimental procedure, while another gets the standard procedure. Of course the disclosure might be different, so it's not completely like a drug trial, where a pt may not know that he/she is getting a placebo.

so i think what pfish is suggesting is a study, where a certain pt pool is presided over by a CRNA indepentendly (or quasi-independently, with an anes standing by) . . .then another pool the standar way (by just an Anes), then compare the two, right?

Basically, this is what I'd be proposing. And the way that I'd sell it is the same way they sell phase I (i.e., the 'we have no idea if this going to kill you' phase) drug trials. By paying the participants. The first round of drug trials, where they determine the safety of the product, are every bit as dangerous as a trial for a new type of surgical technique. They recruit people by paying them money to participate. The phase II and III trials, where you try to determine effectiveness of treatment, are where you just give out discounts or maybe just give people the privlidge of getting the new type of therapy.

 

[pgg]

Basically, this is what I'd be proposing. And the way that I'd sell it is the same way they sell phase I (i.e., the 'we have no idea if this going to kill you' phase) drug trials. By paying the participants. The first round of drug trials, where they determine the safety of the product, are every bit as dangerous as a trial for a new type of surgical technique. They recruit people by paying them money to participate. The phase II and III trials, where you try to determine effectiveness of treatment, are where you just give out discounts or maybe just give people the privlidge of getting the new type of therapy.

Phase I trials are done to establish safety in healthy volunteers (exceptions being dying patients who are willing to try anything, more or less). You want to subject a bunch of healthy people to unnecessary surgery and anesthesia to tease out morbidity and mortality differences between doctor- and nurse-directed care?

The whole point of doing the unethical study outlined previously is to see if sick people having real surgery have different outcomes (or failing that, surrogate endpoints of interest) based on who's delivering the anesthetic. Paying a bunch of college kids whose biggest risk factor is Ramen-induced malnutrition doesn't address address the question at all.

so i think what pfish is suggesting is a study, where a certain pt pool is presided over by a CRNA indepentendly (or quasi-independently, with an anes standing by) . . .then another pool the standar way (by just an Anes), then compare the two, right?

If a patient pool is presided over by a CRNA with an anesthesiologist standing by, then the CRNA is functioning as part of an ACT, and is by definition not working independently.

If you're going to do the study, you randomize real patients to real nurse-only or real doctor-only care, really, for real, and see who dies or strokes or pukes in the PACU, and then you crunch the numbers. Good luck finding an IRB that will approve that.

 

[DrMetal]

If a patient pool is presided over by a CRNA with an anesthesiologist standing by, then the CRNA is functioning as part of an ACT, and is by definition not working independently.

If you're going to do the study, you randomize real patients to real nurse-only or real doctor-only care, really, for real, and see who dies or strokes or pukes in the PACU, and then you crunch the numbers. Good luck finding an IRB that will approve that.

true, ok then it would have to be done that way. And i don't think anyone is proposing 'unnecessary' surgeries. they'd be 'real' and necessary cases. it'd be risky, as would be any experimental procedure. how would you feel having a robot cut into you instead of a human? such trials are going on right now. now that's a lot more risky (i'd think!) than having a CRNA vice an Anes in the room.

in any case, if this is the way anes is going, such a trial will have to take place sometime in the future, in some form or fashion.

 

[Gastrapathy]

in any case, if this is the way anes is going, such a trial will have to take place sometime in the future, in some form or fashion.

Why? Practice patterns have already evolved for CRNA's to coexist with anesthesiologists. The only group likely to undertake such a study are the CRNA's and hopefully no anesthesiologist would be dumb enough to participate.

I heard about the demise of anesthesiology as a medical student in the 90s and it hasn't happened yet. Then again, my mom called because she saw a show on CT colonography and was afraid that I would be out of a job. Doubt thats gonna happen either.

 

[DrMetal]

Why? Practice patterns have already evolved for CRNA's to coexist with anesthesiologists. The only group likely to undertake such a study are the CRNA's and hopefully no anesthesiologist would be dumb enough to participate.

yeah, that's what i meant. if CRNAs are going to be allowed to practice independently, there has to be some data suggesting that they can do so, without any issues. you're certainly right in that anes's probably wouldn't participate in such studies. who would participate in a study that challenges his/her job security!? but maybe they don't have to. you can take a 1,000 standard previous cases (where an Anes was involved) and compare that to a 1,000 new cases, where a CRNA was allowed to work independently.

I heard about the demise of anesthesiology as a medical student in the 90s and it hasn't happened yet. Then again, my mom called because she saw a show on CT colonography and was afraid that I would be out of a job. Doubt thats gonna happen either.

yeah, it certainly hasn't happened yet. but as $$$ and managed care continue to reign, we could see it happen in the near future. I don't mean to sound crass, and perhaps I'm just ignorant about it, but the job of an Anes doesn't seem to be that difficult (day in day out). There's certainly a sweet science to Anes that involves a lot of academics, training, research. But in a medical/surgical context, it seems fairly straight forward, barring some sensitive cases. So it seems like the perfect realm for nursing.

Now GI on the other hand, I think, covers a much wider breadth of medical scenarios. The training isn't just 'academic', it's actual real-life stuff. So I'd much rather my GI be an MD!

 

[notdeadyet]

I don't mean to sound crass, and perhaps I'm just ignorant about it, but the job of an Anes doesn't seem to be that difficult (day in day out).

This is true of much of procedure-based medicine. True of many surgical procedures, true of many GI procedures as well.

Lots of medical fields have about 30% of the work that you can look at from the outside and say, "Gee, that's not too hard." The issue is with the other 70%. Or, more tellingly, what happens when the stuff that was supposed to be easy suddenly.... isn't.

Anesthesiology is a funny gig because until you learn enough to know what they're actually doing, it seems very easy. Once you realize all that's going on and the variables at play, it becomes a lot more impressive.

It's one of those jobs where no one notices if you do it right, but by God you'll get everyone's attention when you don't.

 

[Perrotfish]

Since we're on the subject, does anyone know of studies comparing the effectiveness of NPs/PAs to Docs in a primary care setting?