Salary drop from CRNA

[Eugenie98]

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Also, from an economic perspective, the AANA is like SPAM (the meat substitute).

Claims to be just as good as ham, but cheaper, and more willing to go to scary places that ham just thinks it's too darn good for.

Seriously, from a simple economic perspective the AANA is pushing hard for ALL CRNA's to be viewed as a perfect substitute for MDA's. Why? If not viewed as MDA substitutes the rampup of CRNA mill schools would indeed depress the CRNA salary market drastically as there are only so many cases in which the CRNA could be utilized (think early 1990's). By creating an MDA substitute the number of utilization scenarios drastically increases (demand curve applicable to those MDA-substitute CRNA's shifts to the right).

Whether you like it or not, the CRNA's WILL GET INDEPENDENT PRACTICE RIGHTS, i.e. shift the demand curve to the right for the CRNA market. The only thing that can be done to protect patient safety/quality of care is to prevent the AANA from designating all their CRNA's as MDA equivalents, which is what they want to do with the DNP, and the only way to do that is the same rigorous examination process we require of MDA's.

Unfortunately the AANA will be able to shoot down any attempt at requiring Step I, II, claiming that Step I science is not relevant, that Step II is not needed since nurses already have 'basic clinical experience.' Maybe in the future the step I and II exams could be required for advanced practice nurses (they most definitely should be required), but for now the only hope is to require the ABA exam for all gas MD/DO's and then any CRNA's who want independent practice rights would have to take the step III exam and the written ABA exam.

What I find amusing is that the watered-down step III exam that the DNP Columbia Nursing School students (supposedly the best in the country) take is resulting in 40-50% first-time failure rates versus 4-5% first-time failure rates for 4th year US med students (hell, FMG's only fail at 20% first-time). Plus, what's the saying, two months for Step 1, two weeks for Step 2, a number two for Step 3?

"Perhaps I can be a paralegal and in a few years, get a doctorate and say that I can stand in front of a judge (or jury) and plead my case as well as a JD. Damn the state bar. To hell with torts, contracts, civ pro, con law, ethics and the like. Why learn about legal precedence? I am tired of making less than my supervisors and I do research along with many of the summer interns and 1st year associates. Only thing is I don't want to take the LSAT and go to law school for three years... I just want the same pay. "

 

[Eugenie98]

Also, how about a Flexner report, but for the DNP?

http://en.wikipedia.org/wiki/Flexner_Report


At that time, the 155 medical schools in North America differed greatly in their curricula, methods of assessment, and requirements for admission and graduation. Flexner visited all 155 schools and generalized about them as follows: "Each day students were subjected to interminable lectures and recitations. After a long morning of dissection or a series of quiz sections, they might sit wearily in the afternoon through three or four or even five lectures delivered in methodical fashion by part-time teachers. Evenings were given over to reading and preparation for recitations. If fortunate enough to gain entrance to a hospital, they observed more than participated."


I fear though that might end up legitimizing the DNP.

 

[BLADEMDA]

Also, how about a Flexner report, but for the DNP?

http://en.wikipedia.org/wiki/Flexner_Report


At that time, the 155 medical schools in North America differed greatly in their curricula, methods of assessment, and requirements for admission and graduation. Flexner visited all 155 schools and generalized about them as follows: "Each day students were subjected to interminable lectures and recitations. After a long morning of dissection or a series of quiz sections, they might sit wearily in the afternoon through three or four or even five lectures delivered in methodical fashion by part-time teachers. Evenings were given over to reading and preparation for recitations. If fortunate enough to gain entrance to a hospital, they observed more than participated."


I fear though that might end up legitimizing the DNP.

Glad to have you on Board. Remember, the reality in the hospital is far different than the propaganda promoted by the AANA. That is why I will have a job for many more years. Despite the rhetoric and the claims most CRNAs need a good MD Attending. The Surgeons, Nurses and Administrators know this. Only the huge Egos of some CRNAs prevent them from seeing it as well.

As an Attending I appreciate the quality, fully capable CRNA. But, that is still the exception rather than the norm.

 

[Eugenie98]

Certainly, but how can CRNA's even contemplate the claim of equivalency?

Simple mathetical comparison:
-At a minimum an anesthesiologist has ~7,000 hours of med clinicals ~10,000 hours of anesthesia clinicals ~4,000 hours of didactics.
-A CRNA has ~1,000 hours of nursing clinicals ~1,700 hours of ICU experience ~3,000 hours of anesthesia clinicals and ~1,500 hours of didactics.

To match up on an hours basis:
-If we account ICU experience on a 1 for 1 basis to pre-anesthesia clinical experience, at 36 hours per week x 47 weeks per year it would take ~3 years of additional ICU experience above the 1 year required at 36hx47w.
-If we account post-graduate work as a CRNA on a 1 for 1 basis to account for the difference in clinical training it would take, at 36 hours per week x 44 weeks per year, ~4 years of additional CRNA work experience at 36hx44w.
-To match the didactics it would take ~2 more years of didactics.

So in other words there is a huge multi-year knowledge gap. AANA will use fuzzy math and all sorts of chicanery to claim equivalence, the only way to highlight the hypocrisy is to require the ABA written board exam and step III.

If CRNA's want to bill for the same procedures, handle the same cases independently they should be able to handle the same boards, right?

On the ASA studies, they will only prove the point if thoughtfully designed. CRNA's are certainly capable of handling cases that remain within a certain band of parameters (I'm thinking of a bell curve for morbidities and CRNA's/MD's having equal outcomes within 1 SD of the mean). Say the morbidity of most surgical cases is distributed normally, a study comparing MDA's and CRNA's with the same set of morbidities within 1 SD of the mean will likely show similar outcomes.

When do outcomes differ? I would venture that it's only when the crap hits the fan that outcomes differ. Just as a pilot certified to fly light sport craft could probably fly more complex aircraft in calm weather, no turbulence, with a certified pilot sitting in the passenger area, with a healthy patient, a simple operation, even an SRNA could handle the anesthetics. The study needs to look at outcomes where there are patients with complex co-morbidities and a solo CRNA practitioner, the difference is in the tails (think banking crisis, when everything was hunky dory and sitting in the middle of the distribution all the banks looked the same, rising tide lifts all boats, etc... but when the sht hit the fan one could see what was underneath the facade).

 

[BLADEMDA]

Anesthesia has gotten remarkably safe in recent decades, with roughly one death occurring in every 200,000 to 300,000 cases in which anesthetics are administered during surgery, childbirth or other procedures.
There is not much difference between the two professions in the amount of training they get in administering and monitoring anesthetics. Where the anesthesiologists have a big advantage is in their much longer and broader medical training that, many doctors say, may better equip them to handle complex cases and the rare emergencies that can develop from anesthesia.
From a patient’s point of view, it would seem preferable to have a broadly trained anesthesiologist perform or supervise anesthesia services, but, in truth, the risk is minuscule either way.

 

[335230]

ok

 

[IlDestriero]

Are you seriously suggesting that you didn't see this coming? Nothing has changed since you were in college. The music can't play forever and someone's got to pay eventually. They've been talking openly about severe problems in our medical system and Medicare insolvency and gov't controlled healthcare since well before I went to medical school. CRNAs have been around forever. No one pulled the rug out from under you.🙄 If you're not going to practice anesthesia, don't waste 3 years on a residency. Just change careers now.
Oceanside,
Il D

Blade:

I love your posts brother, but dang I get really depressed. I know you are trying to rally the troops. This profession of physician is dying if not dead, put us in some context.

With medical school accumulating at $200,000 dollars and the interest continuing throughout residency (since 2005), I don't know who is hoping for a great outcome longterm compared to THAT investment in terms of time and money in other professions.

Do you think that this insurance hiking scheme of 20 % , 8 % hikes year after year will continue? Will Healthcare really take up 30 % of the GDP in 10 - 15 years? Answer: Of course not ! I think that it is more likely than not that we end up in a single government payer system. Currently, medicare pays most physicians 70 - 80% of private insurance. It pays us pennies as you know. The last government option program involved medicare rates. So with a "public option" most fields are looking at a 20 % paycut right away. This is not even factoring in SGR / the broken nature of medicare in this country. Hospitals are looking at reduced Medicare contributions over the next few years, not increased - so how will any field's salaries increase if the overall money in the pot is reduced??

OB- midwives, Optho - optometrists, pmr - physical therapist doctors, neurologists - dnp's, cardiology - being bought out by hospitals (PP dead), primary care - np's etc...Who in their right mind would want to invest in a medical practice in this constantly unsure, changing environment?

You are describing a larger narrative of the awful business model we are in - insurance hikes that are unsustainable, a welfare state that is insolvent, and an American public that wants free/cheap care and doesn't care about physicians.

Look at Obamacare - What physician field really benefits? None, Yes some fields get an increase of a small percentage in rates - but without SGR and without malpractice fix etc - does anyone really get that much of a benefit - no in my opinion. There was virtually NOTHING great about the bill for physicians.

This is the wrong field to be in going forward brother. CRNA's have a dismal future too when they pump out CRNA"s like lawyers - soon that market will crash as you have noted.

I don't really have great solutions other than to tell my colleagues to prepare for an exit. I can't tell you how depressing it is to have invested your life in something and then have all the rules changed on you like this. However, I can't lie to myself and pretend that if I somehow switch to field A it will get better. Unless you are in a cash system, outside of insurance you will not be spared these bills. Even then, I am willing to bet that government forces us to take medicare soon.

If anesthesiology goes, soon will go primary care, ob etc etc..either by midlevel nonsense or government nonsense.

I wish we could "turn into Canada" overnight, I don't see it happening like that.

What is next for us dedicated physicians ? I am not sure brother. Dentistry ? MBA ? I don't know. I just wish you would put these continued posts in the context of the ongoing destruction of this profession.

Time to nap after a brutal night on call.

Lakeside,
yours

 

[335230]

ok

 

[mgs]

From my personal experience and from talking to my colleagues, CRNA's are OK for ASA1-2 patients, but they do not have a clue how to manage patients with complex medical problems - example- I walk into my OR and the CRNA is pushing phenylephrine to treat the BP in a patient with severe Pulm HTN- a big no no- she didn't have a clue what to do- and I come across such issues every day- luckily anesthesia is quite safe these days- but when **** hits the fan- you would want a MD not a nurse in the room.

Regards to training- no way are CRNA's equal to physicians- MD go through 4 years of medical school and not nursing school learning how to make up beds!

 

[Stank811]

I love the Irony.

They practice Solo now.

They released new studies proving they are just as safe.

They have the legal right to administer anesthesia without an MD (A).

They get paid the exact same fee from Medicare as a Board Certified MD(A).

They do their "training" in the same locations as many Anesthesia Residents.

They learn from Academic Attendings and Faculty

Then, they take a water-downed exam and claim equivalence to you.

The horse is out of the barn here; the best you can hope for is Academic based studies "proving" more knowledge/skills and SOME HARD MULTIPLE CHOICE QUESTIONS called the ABA written exam.

Blade

The SRNA's around me never compete for cases. We get everything as residents: hearts, neuro, regional, OB etc...they rotate through our peds department but essentially sit in on tubes, T&A's, and dentals all day. It is as simple as limiting their training. Do not teach them what you don't want them to learn. It would be impossible for them to teach their own and compete with physicians. When I see a CRNA or SRNA scheduled for a good learning case while a resident is scheduled for a basic case I send an email to the appropriate people at my program and things often change. Our residents are very vocal to ensure the residents education is not compromised. The real questions is why do other programs allow them to expand their scope to such a large degree...ie mayo, vanderbilt, cleveland clinic, and many others

 

[cincincyreds]

From my personal experience and from talking to my colleagues, CRNA's are OK for ASA1-2 patients, but they do not have a clue how to manage patients with complex medical problems - example- I walk into my OR and the CRNA is pushing phenylephrine to treat the BP in a patient with severe Pulm HTN- a big no no- she didn't have a clue what to do- and I come across such issues every day- luckily anesthesia is quite safe these days- but when **** hits the fan- you would want a MD not a nurse in the room.

Regards to training- no way are CRNA's equal to physicians- MD go through 4 years of medical school and not nursing school learning how to make up beds!

I've never met a cRNA in my life. But basically the AANA feels the cRNAs don't need to pass USMLE 1,2,3 or ABA written boards, or actually read and anesthesia article. Here's the article that the cRNA felt wasn't important to read.

The effect of phenylephrine and norepinephrine in patients with chronic pulmonary hypertension*.

Kwak YL, Lee CS, Park YH, Hong YW.
Source

Anaesthesia Department, Faculty of Medicine, Yonsei University, Seoul, Korea.

Abstract

In this study the effect of phenylephrine and norepinephrine for the treatment of systemic hypotension were evaluated in patients with chronic pulmonary hypertension. When systemic hypotension (systolic arterial pressure < 100 mmHg) occurred following induction of anaesthesia, either phenylephrine or norepinephrine were infused in a random manner to raise the systolic blood pressure by 30% and 50% above baseline values. Norepinephrine decreased the ratio of pulmonary arterial pressure to systemic blood pressure without a change in cardiac index. However, phenylephrine did not increase arterial blood pressure by more than 30% from baseline in one-third of patients and decreased cardiac index without a significant decrease in ratio of pulmonary arterial pressure to systemic blood pressure. These vasoconstrictors showed different systemic and pulmonary haemodynamic effects in patients with chronic pulmonary hypertension as compared to acute pulmonary hypertension. Norepinephrine was considered to be preferable to phenylephrine for the treatment of hypotension in patients with chronic pulmonary hypertension.