Should anesthesiologists and CRNAs stop fighting and join as one?

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

Izzyman

Full Member
7+ Year Member
Joined
Jul 16, 2015
Messages
26
Reaction score
38


Article by Matthew Mazurek, MD.

Personally, I’d be willing to do that if CRNAs worked the same hours (no shift work, break when you can etc) , assumed the same liability, extended their training even more, and went to medical school.

What would it take for you?

Members don't see this ad.
 
  • Haha
  • Like
Reactions: 5 users
I feel like this is a bit of a troll post, but I’m still going to reply.
The article provides us with some nice history. The author also makes an assertion that the cost of healthcare is too high. Seems like the author should have delve into a little bit of WHY the cost of healthcare is too high. Is it because millions and millions of dollars are going to anesthesiologists and nurse anesthetists and nurse practitioners? No. The big money goes to rich corporations, whether they be insurance corporations, hospital corporations, or manufacturing/pharmaceutical corporations. The author conveniently omits that information, probably because he’s interested in kissing up to those same corporations. I don’t care if he studied with Ronald Miller. That doesn’t make him correct about everything.

The fact is that this antagonism between nurse anesthetists and anesthesiologists is because of agitators on both sides.
There are extreme positions on both side of the fence and like in American politics extreme positions are wrong.

1. Anesthesiologist extreme position: “nurse anesthetists don’t know ****.” “Lazy entitled nurses.” I have come across many perpetrators of this extreme position throughout my career and more often than not they are anesthesiologists who do not bring credit to our profession. In my experience, they are the ones who sit in the office, reading newspapers, trading stocks, etc.

2. Extreme Nurse Anesthetist position:
“I know everything that an anesthesiologist does and I have just as good of a grasp of medicine as they do.”
“I deserve to be called doctor because agitators within my profession made up a degree.“ I also have a come across many perpetrators of this position throughout my career, and in my experience the majority of these people need to shut up their mouths and read more science to improve their lacking clinical skills.

The truth is that both of these extreme positions are wrong, and the vast majority of providers in the anesthesia world do not endorse these positions.
 
  • Like
Reactions: 3 users
Members don't see this ad :)
Sure, once “mid levels” open their own hospitals and clinics without physician “interference” along with their chiropractor and dental “associate” counterparts then we can have a conversation about value propositions.

Until then, we are stuck at an impasse.
 
  • Like
Reactions: 1 users
Sure, once “mid levels” open their own hospitals and clinics without physician “interference” along with their chiropractor and dental “associate” counterparts then we can have a conversation about value propositions.

Until then, we are stuck at an impasse.
Along with advancing their field thru research and only learning from other crnas (including but not limited to tee) and never having the option to “phone a doc” in case of a problem.
 
  • Like
Reactions: 1 user
While i agree with many of his anecdotes (I have learned techniques and different ideas from CRNAs in training, where I work at now, etc) and would like for the political battles between CRNAs and Anesthesiologists to go away, the fundamental issue I have is CRNAs come out of training with less required experiences and formalized, rigorous training than anesthesiologists.

Sure nurses were the first “providers” of anesthesia, but applying the practice of medicine to anesthesiology has brought patient safety to the forefront. Physician scientists/researchers are responsible for the vast majority of the technology advances in this field that have made this attainable.

Residents go through an often grueling 4 year educational program where they have a high number of case minimums, see perioperative or anesthetic complications while delivering care, and develop a plan to manage those complications. They are surrounded by mentors that contribute to the most recent literature and practice guidelines. Most leave residency with many things to learn, but the fundamentals are there.

Meanwhile some CRNAs come from quality programs that have excellent clinical experiences while others can meet their “numbers” by observing someone do a regional nerve block or watching a video on central line placement. I for one am not interested in teaching CRNAs and bridging the post CRNA school education gap while caring for patients.

Unfortunately there is much to gain for corporations in this country by “leveling” the pay of Midlevels and physicians. Hospital admins won’t care if cases get done, even if less qualified anesthesia providers are sitting stool. I admire Dr. Mazurek for trying to bring unity to CRNAs and anesthesiologists, but this article fails to acknowledge the very real difference in education and skill sets (at least for “providers” fresh out of training)
 
  • Like
Reactions: 1 users
A paralegal is not a lawyer who is not a judge
A cadet is not a colonel who is not a general
A poly-sci freshman is not a PhD candidate who is not a tenured professor
A nurse is not a CRNA who is not an anesthesiologist

Like it or not, there is training, knowledge, experience, and testing that is missing at every lower rung. 95% of the time your average CRNA will function just as well as your average anesthesiologist. It's that 5% of the time, which influences outcomes, when the physician shines and makes the difference. Medicine has made some incredible leaps over time and has become increasingly safer. We now try to prevent and stave off the "never event" or salvage a ongoing disaster and this is where a physician versus a nurse makes the biggest differences.

CRNAs want the money and prestige without the hard work and higher level education and training. If they want that, they can take the MCAT, go through med school, complete a residency, and join me as an equal. Until then, they are not my equal.

Never forget than the best and the brightest coming out of high school want to become doctors. No valedectorian aims to become a nurse training at the top of their license. Everything else is marketing, propaganda, and spin.
 
  • Like
Reactions: 15 users
The first providers of anesthesia were untrained lay people and medical students. Nurses came later. Anesthesiology became a medical specialty when it was realized that too many people were dying from anesthesia and that knowledge of Medicine and good planning saves lives in the OR
 
  • Like
Reactions: 9 users
When they graduate medical school and residency I'll happily consider them a colleague.
 
  • Like
Reactions: 6 users
What percentage of MDs and CRNAs are actively fighting? Versus working together in a care team model? Unfortunately our mainstream media has made a business of selling despair and conflict in our country. :(
 
  • Like
Reactions: 1 user
What percentage of MDs and CRNAs are actively fighting? Versus working together in a care team model? Unfortunately our mainstream media has made a business of selling despair and conflict in our country. :(

Depends what you mean by “actively fighting”.

There is a difference between working together congenially with people who are truly content with the physician led care team and working civilly with people who radiate an undercurrent of suppressed resentment and animosity towards our status and very presence.
 
  • Like
Reactions: 8 users
95% of the time your average CRNA will function just as well as your average anesthesiologist. It's that 5% of the time, which influences outcomes, when the physician shines and makes the difference.
I mean no offense but I, a lowly psychiatrist, provide better care than a vast majority of PMHNPs (or whatever acronym they use these days). Since you say the average anesthesiologist provides equal care 95% of the time, then I can only say: I don't believe you.
 
  • Like
Reactions: 1 user
Members don't see this ad :)
I mean no offense but I, a lowly psychiatrist, provide better care than a vast majority of PMHNPs (or whatever acronym they use these days). Since you say the average anesthesiologist provides equal care 95% of the time, then I can only say: I don't believe you.
Sadly it's pretty much true now that anesthesia is so safe.

Most cases and anesthetics are pretty straightforward.

I have had a few cases over the years when I truly saved a life that would be lost otherwise.

The rubber hits the road when you have a really crappy airway or the SHTF otherwise in the OR.
 
  • Like
Reactions: 2 users
Sadly it's pretty much true now that anesthesia is so safe.

Most cases and anesthetics are pretty straightforward.

I have had a few cases over the years when I truly saved a life that would be lost otherwise.

The rubber hits the road when you have a really crappy airway or the SHTF otherwise in the OR.
Oof. I'm happy for patients but saddened about the state of anesthesiology if this is true.
 
The truth of the matter is that anesthesiology is meant to be a specialty that includes the practice of critical care. It’s a shame more people don’t do it.

I can’t even count how many times my role in the icu or as a critical care consultant on the floor has directly lead to a patient either surviving the hospital admission or at the very least avoiding major morbidity. I can not say the same when I am doing outpatient anesthesia. Let’s be real. Arch is right, maybe a handful of times I’ve done something special in the OR.

I respect my PA/NP/CRNA colleagues immensely but patients/doctors/administrators know the difference between a competent physician in the icu and an average NP/PA.
 
I respect my PA/NP/CRNA colleagues immensely but patients/doctors/administrators know the difference between a competent physician in the icu and an average NP/PA.

They know, do they care, that’s the question. And also let’s be real, most of the icu patients in this country, don’t belong there, nor can they really be saved.
 
They know, do they care, that’s the question. And also let’s be real, most of the icu patients in this country, don’t belong there, nor can they really be saved.
Hm. I think they do care. Here are a few reasons:

1) better outcomes = improved reputation in the community = $
2) ED, Hospitalists, surgeons feel supported
3) leadership in administration. Quality improvement which = $
4) I honestly believe that most administrators care whether humans that come into the hospital are getting treated well. (Sociopaths aside)

As to your other point, I agree. I wish I had more latitude in saying “No.” maybe it will change in my lifetime. Does not counter my statement that I as a physician make a tangible impact in the lives of patients in the hospital. I get a lot more professional satisfaction out of my ICU patient interactions than I do in the OR. I really wish more anesthesiologists would choose the icu path. If you look on gasworks you’ll see a lot more private groups hiring for combo positions. Also, I think it’s getting to the point that ICU is paying more than many anesthesia only gigs I see.
 
Oof. I'm happy for patients but saddened about the state of anesthesiology if this is true.

It is a testament to the efforts of those who came before us and made it possible. We've come a long way from dumping chloroform on people's faces
 
Hm. I think they do care. Here are a few reasons:

1) better outcomes = improved reputation in the community = $
2) ED, Hospitalists, surgeons feel supported
3) leadership in administration. Quality improvement which = $
4) I honestly believe that most administrators care whether humans that come into the hospital are getting treated well. (Sociopaths aside)

As to your other point, I agree. I wish I had more latitude in saying “No.” maybe it will change in my lifetime. Does not counter my statement that I as a physician make a tangible impact in the lives of patients in the hospital. I get a lot more professional satisfaction out of my ICU patient interactions than I do in the OR. I really wish more anesthesiologists would choose the icu path. If you look on gasworks you’ll see a lot more private groups hiring for combo positions. Also, I think it’s getting to the point that ICU is paying more than many anesthesia only gigs I see.

I won’t agree or disagree. I also want you you look at some of these threads in the forum. (Sure maybe it’s slanted, since it’s SDN after all….) midlevel is trying to get into everything, and anything that they can. Even your community NICU and PICU now probably has a midlevel presence. There were a few threads about crna taking over some hospitals, do the admin really care? If it’s a for profit hospital/health care system, they’re ultimate obligation is not to the patients, I am sorry to say. No matter how good the administration’s intention is.

I did not want to do icu work. We are anesthesiologists, first and foremost…. We shouldn’t change my job description, because crna “believe” they’re as good…. Or some “research” to show there’s no outcome difference.
 
I can’t even count how many times my role in the icu or as a critical care consultant on the floor has directly lead to a patient either surviving the hospital admission or at the very least avoiding major morbidity. I can not say the same when I am doing outpatient anesthesia. Let’s be real. Arch is right, maybe a handful of times I’ve done something special in the OR.
I dunno - even with outpatient anesthesia, someone has to be able to stand up and say NO to the surgeon or endoscopist when inappropriate patients present at outpatient facilities. CRNAs, especially if employed by the center, aren't likely to do that. I'm aware of a brand new group in my area that is already having issues with this very problem, and the owners (not just the operating physician) were incensed that a CRNA would dare cancel a case.
 
I dunno - even with outpatient anesthesia, someone has to be able to stand up and say NO to the surgeon or endoscopist when inappropriate patients present at outpatient facilities. CRNAs, especially if employed by the center, aren't likely to do that. I'm aware of a brand new group in my area that is already having issues with this very problem, and the owners (not just the operating physician) were incensed that a CRNA would dare cancel a case. Why? Well because they're not a physician of course.
 
I won’t agree or disagree. I also want you you look at some of these threads in the forum. (Sure maybe it’s slanted, since it’s SDN after all….) midlevel is trying to get into everything, and anything that they can. Even your community NICU and PICU now probably has a midlevel presence. There were a few threads about crna taking over some hospitals, do the admin really care? If it’s a for profit hospital/health care system, they’re ultimate obligation is not to the patients, I am sorry to say. No matter how good the administration’s intention is.

I did not want to do icu work. We are anesthesiologists, first and foremost…. We shouldn’t change my job description, because crna “believe” they’re as good…. Or some “research” to show there’s no outcome difference.
I think I’m trying to make a few points. One is that ICU is an important, fulfilling, and appreciated position in the hospital system. It’s been my experience that physician involvement leads to improved patient outcomes on a daily basis. I agree that I don’t care what some retrospective/flawed studies showed.

Another point is that I don’t think being an anesthesiologist is mutually exclusive to being an intensivist. I feel that our specialty is supposed to encompass both. That’s the case in pretty much every other country. I think that If that was emphasized and that position leveraged, we really wouldn’t be having these conversations
 
I think I’m trying to make a few points. One is that ICU is an important, fulfilling, and appreciated position in the hospital system. It’s been my experience that physician involvement leads to improved patient outcomes on a daily basis. I agree that I don’t care what some retrospective/flawed studies showed.

Another point is that I don’t think being an anesthesiologist is mutually exclusive to being an intensivist. I feel that our specialty is supposed to encompass both. That’s the case in pretty much every other country. I think that If that was emphasized and that position leveraged, we really wouldn’t be having these conversations

I don’t know how icu care is done in other countries. I can only imagining that there aren’t so many ways to get to critical care medicine like we have in this country. You have IM/EM/Anesthesia all fighting for the same patients. I am sure IM physicians won’t be the friendliest if they are a private pulm group. We all know in this country, being in ICU doesn’t pay. I am sure your salary is subsidized by the hospital. Know of a physician who is a anesthesia to CCM and hired by the hospital to do ICU, but unable to practice anesthesia because the anesthesia is private….

All this patient center “stuff” is all good in theories, but unfortunately we all have to operate within the system that we have, and I don’t believe admin or the system has us let alone patient in mind.
 
I remember reading this article before choosing to apply to anesthesiology residency programs.

I like the recent historical recount provided by @Propofologist buried in the comments on a recent article written by a CRNA (https://www.anesthesiologynews.com/Commentary/Article/11-21/Anesthesiology-Team-Model-Care/65145)

The U.K. does not allow any sort of autonomous midlevel anesthesia. Furthermore, the midlevels that have evolved are tightly controlled by the Royal College of Anaesthetists. (Google: “An American tale – professional conflicts in anaesthesia in the United States: implications for the United Kingdom” and check out British Anaesthetic & Recovery Nurses Association) So, how did we get into this mess in the US? One key piece of the historical puzzle is found by looking at ether and chloroform. Chloroform was used in the U.S. in the mid-1800s. You will particularly find stories about it used on the Civil War battlefields for quick amputations. It took far less chloroform than ether to induce an insensible state, and the induction was far more rapid and deeper (to the point of apnea) than ether. But, chloroform's kill rate, particularly when it caused fatal arrythmias on induction, was well known (albeit not well understood) and hotly debated. Chloroform was never popular in private practice in the U.S. compared to ether. What is more, the early proponents of anesthesia in the U.S. (e.g., Morton) were opportunists mainly looking to make a buck off ether by patenting it as "letheon" after adding a dye and fragrance. Morton was a part-time dentist who never finished medical school. He was certainly not a dedicated scientist like the British doctors Snow and Simpson. Not even close. And ether was so much easier and relatively safer to use. So, for example, you will find early U.S. female nurses like Alice Macgaw, who worked closely with the Mayo brothers in the late 1800s, lauding ether's safety at the turn of the last century in major medical publications. Macgaw claimed that she had given over 14,000 anesthetics with ether without a single death. Google it, that's easy to find. By comparison, Snow realized chloroform's extreme danger, but his surgeons still preferred it because, for example, patients didn't go through a protracted excited stage on lengthy inductions, and they were much less likely to move intraoperatively. And Simpson was adamantly promoting it despite the kill rate. So, from the beginning, Snow was all about figuring out how chloroform could be safely administered. For example, Snow was very focused on breathing apparatus to titrate chloroform and he studied physiologic changes--much like the doctor Arthur Guedel decades later in the U.S.--to account for safe depths of anesthesia. The point is that the attitude in England quickly developed that only a doctor could possibly administer such a dangerous substance like chloroform, whereas in the U.S. the attitude quickly developed that anyone could give ether--and just about anyone did. In fact, for the first 100 years after 1846, after Morton’s “letheon” and before WWII, female nurses, not doctors, were the ones giving anesthesia for male surgeons most of the time. By the time doctors figured out anesthesia was a deal, it was too late in this country. Surgeons went to bat time after time for their nurse anesthetists and shut down every challenge that doctors (like Francis Hoeffer McMechan the founder of IARS) made against nurses to state medical boards and state legislatures. This is easily confirmed by googling “Alice Macgaw,” "Mother of Anesthesia," and Charles Mayo (a founder Mayo Clinic). Another good example, google Agatha Hodgins (founder AANA), George Crile (founder of Cleveland Clinic), and Lakeside School of Anesthesia. The result is today, in EVERY state in the U.S., CRNAs have the legal right to practice without an anesthesiologist anywhere nearby. At most, they only need a surgeon in the room. Some hospitals' bylaws get around this by requiring anesthesiologists to supervise, but no state's law requires it. You can also look back and see how early doctors like McMechan had no idea that healthcare was about to explode and there was no way an MD only system could cover it even if only doctors could practice anesthesia. What I believe that he, and later the ASA, fundamentally failed to do was gain early control of the training and licensing of nurse anesthetists like the Royal College of Anaesthestists has done in the UK. Instead of confronting nurse anesthetists directly and containing the problem, early leaders in the ASA focused on developing an alternative—the Anesthesia Assistant. (See Dripps, Decisions for a specialty in Bulletin of the New York Academy of Medicine Vol. 38 Issue 4 Pages 264-270 1962; J. Steinhaus, et al., Analysis of manpower in anesthesiology, Anesthesiology 1970 Vol. 33 Issue 3 Pages 350-356; and J. Steinhaus, et al., The Physician Assistant in Anesthesiology?, Anesthesia & Analgesia 1973 Vol. 52 Issue 5 Pages 794-798.). This seemed like a good idea at the time. In the 1970s, CRNAs had no way to direct bill Medicare and there were no limits on supervision. If I wanted to supervise 10 nurses in 10 rooms giving anesthesia, bill Medicare for my anesthesia services, and pay the nurses and pocket the difference, I could. But that quickly changed because healthcare costs mushroomed. In the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA), Medicare was given authority to push back on leveraging CRNAs with the concept of “medical direction.” So now it was only four CRNAs (or AAs) and only if you carefully followed seven steps that Medicare decided showed your personal involvement in the cases. To me, that has made AAs a dead end. I hate doing medical direction. Everyone knows there isn’t a prayers chance in hell you can medically direct four busy rooms, particularly at the start of the day. Steinhaus obviously had no clue how his AA work around would play out. Two other critical changes followed. CRNAs gained the right to direct bill Medicare under part B of the system just like doctors, and then, they were given the ability to direct bill Medicare with a “QZ” designation that effectively allowed them to get paid even if they worked independently and at the same conversion factor rates anesthesiologists are paid (currently around a whopping $20/RVU--but that's another story). These developments are what has allowed groups like Nurse Rodriguez’s, Arizona Anesthesia Solutions, to get paid and thrive. Now, I am skipping a lot, but fast-forward to today's milieu of tight money and the fact that a typical CRNA costs half or less than an anesthesiologist does. So, in the recent past, private investors buy out thousands of expensive (and many soon to retire) anesthesiologists, replace them in the ORs with far cheaper CRNAs, and pocket a ton of money. Unfortunately, many of these short-sighted deals are facilitated by our very own. Of course, the ASA's touting the team model and promoting CRNA supervision in the perioperative surgical home only throws gas on this wildfire. And, these private equity-backed groups make all kinds of arguments about improved quality of care, the complexity of medical record-keeping, work-life balance, . . . yadda, yadda, yadda. But, the bottom line is anesthesia in the U.S. is being turned into a widget factory, and U.S. anesthesiologists are being reduced to computer-screen-clicking CRNA (and AA) babysitters who are disincentivized. They are paid a largely flat salary that has no relation to productivity. In fact, the harder you work, the less you make. Everyone is watching the clock to get out. Furthermore, you are hearing of more and more independent CRNA practice—it’s the cheapest business model by far after all. And the ASA is fiddling while Rome is burning. Just look, for example, at all the private equity-driven groups supporting the last ASA annual meeting in San Diego in October. We need some new ideas focused on the business of anesthesia, productivity and the inherent value doctors can bring . Now. One thing the ASA must do is change its marketing campaign---mindful of the FTC-- to get the public to understand that unless they demand MD led care they may very well be walking into an OR that only has nurses putting them to sleep with no doctors involved at all. We can dump on each other all day long about safety, training, etc. but ask the consumers would you rather have a doctor, a nurse closely led by a doctor, or a nurse without any doctor’s oversight put you to sleep. Let the public decide this fight and let that direct how anesthesia continues to evolve in the U.S. That’s a no brainer and I do not feel the ASA is getting aggressive enough (compared to AANA and their “anesthesiologist” rebrand, for example) given all the foregoing.

I absolutely love that this guy pointed out what I believe is the most important problem in the discussion: billing incentives. Who the hell cares what nurses were doing 150 years ago when the most important detail happened in the 1980s when the government decided for everyone how valuable this service is regardless of how much time was spent learning the craft. From the point of view of a CRNA the question is "why shouldn't I spend my ICU shift studying for the GRE?" whereas a physician asks "why would anyone want to spend a decade of life working just to end up here?"

I think Mazurek's point is view is not helpful in answering these questions. If you cannot place this discussion in the context of warped billing incentives then the discussion is just as useless as Mazurek makes physician clinicians out to be. I think if Mazurek took his own advice he would ask himself why he doesn't just quit and give his job to a CRNA. He probably realized just as much and decided to become an administrator (he lists himself as a "physician executive"). As it turns out, billing incentives also strongly encourage upward mobility. It's a slap in the face to those who still value their role in clinical medicine and strongly desire to be clinicians throughout their career. You have to have an answer to this question, and ideally a thoughtful answer that does not come at a cost to everyone else.
 
Last edited:
  • Like
Reactions: 3 users
It is a testament to the efforts of those who came before us and made it possible. We've come a long way from dumping chloroform on people's faces


Chloroform was never popular here. It took a skilled UK trained physician anesthetist to use that stuff. ;)
 
  • Like
Reactions: 1 user
I think I’m trying to make a few points. One is that ICU is an important, fulfilling, and appreciated position in the hospital system. It’s been my experience that physician involvement leads to improved patient outcomes on a daily basis. I agree that I don’t care what some retrospective/flawed studies showed.

Another point is that I don’t think being an anesthesiologist is mutually exclusive to being an intensivist. I feel that our specialty is supposed to encompass both. That’s the case in pretty much every other country. I think that If that was emphasized and that position leveraged, we really wouldn’t be having these conversations
Years ago, I posted on SDN that Critical Care should be included in your residency training. 4 years. Base year is 6 months critical care and 6 months of various rotations. CA1-CA3 years would include another 6 months of Critical Care. When you complete those 4 years you now qualify for the Certification exam in both critical care and anesthesiology. The fellowship year would still exist by altering the critical care certificate to "advanced" critical care for those doing an additional year. Most community ICUs could be run by those with basic certification while academic ICUs have advanced certification.

The time is long past that this specialty stop watering down the 4 years and put some teeth into it. There is no reason anyone should need to spend more than 5 years in training to do this specialty with a fellowship
 
  • Like
Reactions: 1 user
This guy Mazurek has a lot less experience than I do. I too trained at an elite academic center with CRNAs. My experience far exceeds his own by at least one decade, if not longer, and tens of thousands of anesthetics.

I say this not to put him down or elevate myself but rather to make a point: CRNAs lack the medical education to care for patients. They know how to give an anesthetic and even how to perform many procedures. What they lack is the knowledge to deal with complex medical issues which arise both preoperatively and postoperatively. Specifically, the preop evaluation is fundamental to the care of the patient. In this day and age of outpatient surgery of ASA 3 patients, a proper preop evaluation followed by the appropriate intraop anesthetic is key to a successful, safe operation leading to discharge home.

Hence, I support the need for a physician requirement to oversee the anesthetic to place the responsibility for the well-being of the patient on a physician and not a nurse. Even if I agree to leave the anesthetic decision to the CRNA the physician remains responsible for the outcome of the case. There is a reason my malpractice insurance costs 3 X more than a CRNA and I firmly believe it isn't because they are 3 X safer.

If a surgeon or dentist wants to hire and supervise a CRNA then the outcome of that case falls on that surgeon. Only the "anesthetic portion" of the care is the responsibility of the CRNA. The law should remain as it stands.
 
  • Like
Reactions: 2 users
Sadly it's pretty much true now that anesthesia is so safe.

Most cases and anesthetics are pretty straightforward.

Anesthesia is NOT safe. Nothing kills ( or worse, renders you a Vegetable) faster than a Bad Anesthetic. Patients should be and are mostly terrified of Anesthesia. They are smarter than most Anesthesiologists on this Board.

Come back to this post when your Family member is undergoing Anesthesia with 1:8 Supervision ratio or even worse an Independent CRNA...because of the impotence and incompetence of the ASA...that is where the Field is headed.
 
Anesthesia is NOT safe. Nothing kills ( or worse, renders you a Vegetable) faster than a Bad Anesthetic. Patients should be and are mostly terrified of Anesthesia. They are smarter than most Anesthesiologists on this Board.

Come back to this post when your Family member is undergoing Anesthesia with 1:8 Supervision ratio or even worse an Independent CRNA...because of the impotence and incompetence of the ASA...that is where the Field is headed.
Clearly you've never seen someone shot in the head with an M2 browning.
 
Years ago, I posted on SDN that Critical Care should be included in your residency training. 4 years. Base year is 6 months critical care and 6 months of various rotations. CA1-CA3 years would include another 6 months of Critical Care. When you complete those 4 years you now qualify for the Certification exam in both critical care and anesthesiology. The fellowship year would still exist by altering the critical care certificate to "advanced" critical care for those doing an additional year. Most community ICUs could be run by those with basic certification while academic ICUs have advanced certification.

The time is long past that this specialty stop watering down the 4 years and put some teeth into it. There is no reason anyone should need to spend more than 5 years in training to do this specialty with a fellowship
I agree with this 💯.
I never understood why critical care rotations were not a bigger part of anesthesiology residencies, as the majority of ICUs around the world are staffed by anesthesiologists.

Not only should anesthesiology residencies have more required ICU rotations, they should be in every subsection of ICU (ie medical, neuro, cardiac, not only surgical)

I contemplated doing a critical care fellowship only to gain more experience, but sadly couldn’t handle the emotional toll that comes with it.
 
  • Like
Reactions: 1 user
Meh to those who say ICU is the safe specialization. Lots of the white tower institutions have 1 year 'fellowships' for inexperienced untrained, under educated mid-levels.
Disclaimer: I am an intensivist.
 
  • Like
Reactions: 3 users
Meh to those who say ICU is the safe specialization. Lots of the white tower institutions have 1 year 'fellowships' for inexperienced untrained, under educated mid-levels.
Disclaimer: I am an intensivist.
Not saying it’s “safe”
But definitely adds more value to our training no doubt
 
Meh to those who say ICU is the safe specialization. Lots of the white tower institutions have 1 year 'fellowships' for inexperienced untrained, under educated mid-levels.
Disclaimer: I am an intensivist.

I dont think current residents should do ICU because its "safe."

If one does not like complex vent management, shock management, resuscitation, diagnosing and treating various infectious diseases, staying current on cardiac output/perfusion monitors, actually leading ACLS, airway management, etc IN ADDITION TO OR anesthesia, you shouldnt go into "Anesthesiology" and be upset that CRNAs do the exact same thing you do. You should think really hard about what speciality you want to do.

Im aware of the "fellowships" for PAs/NPs. Anyone who actually practices critical care knows that you are using all the tools you learned in medical school. Not to mention basic science principles such as physics/chemistry/Calculus that we had to cover as pre-meds. Again, i have tremendous respect for my colleagues who show up and want to work hard and learn, but I stopped being surprised at the lack of depth in knowledge when it comes to every day things were are doing in the ICU. There is a difference between a physician leader and a well trained NP/PA. Maybe Im naive but I feel like my co-physicians, nurses, Administrators can spot the difference and care.

Im also empathetic to those who have a hard time with the emotional aspects of critical care. Its not easy. However, some of my most personally fulfilling days are after a long family discussion where I help family come to the right decisions for their family members. Trust me, if you get frustrated at the lack of respect in the OR, you should see the gratitude family's express after they see you give everything for their loved ones.
 
Im aware of the "fellowships" for PAs/NPs. Anyone who actually practices critical care knows that you are using all the tools you learned in medical school. Not to mention basic science principles such as physics/chemistry/Calculus that we had to cover as pre-meds
Agree, but the same applies to intraop anesthesiology. But when done right no one often notices the difference between ' algorithmic, this is the way we always do it, CRNA care (because safety of elective surgery/ anesthesia) versus deliberate thought and action that physicians should bring.
I relatively like ICU medicine (intellectual challenge, families etc) but let's not fool ourselves. Nurses and mid-levels have told me
explicitly that they believe themselves equivalent. And it's a rare administrator (physician or not) that cares about outcomes beyond $$$. While many paoers show decrease in ICU cost/time in hospital with an intensivist running the show, good luck showing that on a balance sheet. Anyways, with much of our current system ordering unecessary testing, time in hospital, unecessary consultants can pad the bill and increase hospital revenue...
 
  • Like
Reactions: 1 user
Agree, but the same applies to intraop anesthesiology. But when done right no one often notices the difference between ' algorithmic, this is the way we always do it, CRNA care (because safety of elective surgery/ anesthesia) versus deliberate thought and action that physicians should bring.
I relatively like ICU medicine (intellectual challenge, families etc) but let's not fool ourselves. Nurses and mid-levels have told me
explicitly that they believe themselves equivalent. And it's a rare administrator (physician or not) that cares about outcomes beyond $$$. While many paoers show decrease in ICU cost/time in hospital with an intensivist running the show, good luck showing that on a balance sheet. Anyways, with much of our current system ordering unecessary testing, time in hospital, unecessary consultants can pad the bill and increase hospital revenue...

I get your point. I disagree however that the differences are not more noticeable in the ICU. You can get away with a lot in the OR. We all know this. I dont agree that that leeway occurs to the same degree in the ICU/Hospital ward.
 
I get your point. I disagree however that the differences are not more noticeable in the ICU. You can get away with a lot in the OR. We all know this. I dont agree that that leeway occurs to the same degree in the ICU/Hospital ward.


FWIW I see more profound and longer duration of hypotension being tolerated in our ICUs and wards than we would ever allow in the operating rooms. Easily correctable but they seem to just sit on it. Sometimes I look at the vital sign flowsheet and I am shocked;)
 
  • Like
Reactions: 1 users
FWIW I see more profound and longer duration of hypotension being tolerated in our ICUs and wards than we would ever allow in the operating rooms. Easily correctable but they seem to just sit on it. Sometimes I look at the vital sign flowsheet and I am shocked;)
Agree 100x. No urgency/stress to treat hypotension.

I disagree however that the differences are not more noticeable in the ICU
I think most of the outcomes for truly sick patients is fixed, it's only a certain small percentage of the population that can be influenced. Obviously I'm a negative Nancy/fatalist. And prevent (iatrogenic) mistakes, which cause harm.
 
  • Like
Reactions: 1 user
Agree 100x. No urgency/stress to treat hypotension.


I think most of the outcomes for truly sick patients is fixed, it's only a certain small percentage of the population that can be influenced. Obviously I'm a negative Nancy/fatalist. And prevent (iatrogenic) mistakes, which cause harm.
I’ve seen previous discussions on that first point on this board. I think a lot of my anesthesia (non intensivist)colleagues don’t spend enough time in the icu to understand what’s going on on a day-to-day basis.

On the second point, I firmly disagree with you. Maybe your view has been skewed from a residency experience or perhaps less than stellar icu staff? Do agree that prevention of harm is a key thing we should be doing intra op and in the icu
 
It is a testament to the efforts of those who came before us and made it possible. We've come a long way from dumping chloroform on people's faces
Don't forget ether, and it was hardly 'dumping'. That was when anesthesia was hard....
 
  • Like
Reactions: 1 user
I tried that before. Marriage lasted about a year. We already have a model that works ACT. Docs need to hire the crnas. That should change the dynamic.
 
Sadly it's pretty much true now that anesthesia is so safe.

Most cases and anesthetics are pretty straightforward.

I have had a few cases over the years when I truly saved a life that would be lost otherwise.

The rubber hits the road when you have a really crappy airway or the SHTF otherwise in the OR.
I’m only just finishing my MS3 rotations, and I’ve lost count of the number of times I’ve seen a CRNA struggle for 20 mins to do a spinal only to have them finally ask for help and have the anesthesiologist come in and do it in less than a minute. Any time you are in the OR and preventing a patient from suffering at the hands of an undertrained “provider” you are doing something special.
 
  • Like
Reactions: 2 users
I’m only just finishing my MS3 rotations, and I’ve lost count of the number of times I’ve seen a CRNA struggle for 20 mins to do a spinal only to have them finally ask for help and have the anesthesiologist come in and do it in less than a minute. Any time you are in the OR and preventing a patient from suffering at the hands of an undertrained “provider” you are doing something special.

Same. Im a young attending in my early 30s and work with some CRNAs that are in their 50s. A couple of times I let them attempt the spinal and they struggle so much I don't even understand the angles they're attempting and meanwhile the patient is uncomfortable from all the poking. I take over and get it within a minute. Now I don't even let them attempt anymore.
 
  • Like
Reactions: 1 users
I’m only just finishing my MS3 rotations, and I’ve lost count of the number of times I’ve seen a CRNA struggle for 20 mins to do a spinal only to have them finally ask for help and have the anesthesiologist come in and do it in less than a minute. Any time you are in the OR and preventing a patient from suffering at the hands of an undertrained “provider” you are doing something special.


Unfortunately this also happens with anesthesiologists.
 
  • Like
Reactions: 1 users
Good luck with that.

Let's attack AA as well.

265796598_10100906534963601_1363177566501466516_n.jpg
 
Top