SRNA "Resident"

[Charles_Carmichael]

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probably the most damning thing above, given that its probably 30% of what I did in CA1-CA3 (excluding pain, ICU, OB, etc.)

I'm surprised they didn't convert the 1400 hrs into seconds and present that number instead.

"By the time they graduate, each Webster nurse anesthesia resident has administered 5,040,000 seconds of anesthesia to patients."

 

[IlDestriero]

Quite frankly, I wouldn’t trust a CRNA to handle my anesthesia.....even under the supervision of an anesthesiologist. I’ve witnessed first-hand in the OR how some of the more ballsy CRNAs are a bit hesitant to call in the anesthesiologist when something isn’t right, and instead try to troubleshoot problems themselves first. That’s not gonna cut it for me if I ever need to go under GA for anything (and I’m the epitome of an ASA-1). I’d much rather have the expert physically present at the head of my bed, thank you very much!

You may have some problems with this request. That's not an option at many hospitals. Here, we do some of our own cases, but we will not accommodate that request from a parent. You can request a particular anesthesiologist, but we don't even guarantee that. It's too disruptive to the master schedule to move people around. Of course, you're free to go elsewhere and take your chances with a different team.

 

[Mman]

Correct me if I’m wrong, but don’t most anesthesia problems occur closer to the time of induction or recovery? Counting the number of hours of “anesthesia” they deliver doesn’t seem like a very good way of estimating their ability to handle the complicated aspects of anesthesia. I’d think that the number of cases would be a better estimate. By virtue of the fact that you guys spend three years training on anesthesia while they spend one year on anesthesia (and one year training on easier patients as student CRNAs rather than anesthesiology residents), one would assume that you’ve got a hell of a lot more training, period. Just a thought.

The funniest thing to me would be to simply look at their case logs. Look at what kind of cases and how sick the patients were they took care of. The bare minimum requirements to graduate as a CRNA are almost nothing. That's why there are some CRNAs that are just so bad, the bar they have to clear is so low that almost anybody with a pulse can make it through.

Don't get me wrong, there are some great CRNAs out there that do a phenomenal job clinically and could have gone to medical school if they wanted to, but they chose a different path in life and that's fine. They do a good job and know when to call for help or just my opinion. But the worst of the worst are pretty damn bad. And if somebody wants to legislate independent practice, they are telling you that the absolute worst CRNA out there is safe and capable of providing any anesthetic to any patient.

That's when I start laughing at them and fearing for the future of health care in our country.

 

[Mman]

You may have some problems with this request. That's not an option at many hospitals.

Agreed. There isn't an MD only model within at least 300 miles of my hospital and that covers a population of more than 4 million people, unless you count MDs supervising residents, but those places also have MDs supervising CRNAs.

There will never be enough anesthesiologists in the US to provide 1 on 1 care for every anesthetic. Can't and won't happen. But I'm 100% sure that they care my ACT provides is at least equivalent to an MD only model in terms of patient safety and in several ways superior in terms of patient satisfaction.

 

[FutrrENT]

You may have some problems with this request. That's not an option at many hospitals. Here, we do some of our own cases, but we will not accommodate that request from a parent. You can request a particular anesthesiologist, but we don't even guarantee that. It's too disruptive to the master schedule to move people around. Of course, you're free to go elsewhere and take your chances with a different team.

As a doctor and specifically a surgeon, I’m sure that’s an accommodation that the anesthesiologists would be willing to make! Besides, there are some cases that are slated to have anesthesiologists (or residents) present from start to finish. So it does happen. But like I said, over my dead body would I allow a CRNA to stand at the head of my bed and make decisions for my health while I’m within an inch of death - which is pretty-much what all anesthesia is. As far as I’m concerned, that’s physician territory. If there are patients that are too dumb to care and are content with a nurse handling it for them, then they have that choice. Again, it’s not acceptable for me.

 

[FutrrENT]

The funniest thing to me would be to simply look at their case logs. Look at what kind of cases and how sick the patients were they took care of. The bare minimum requirements to graduate as a CRNA are almost nothing. That's why there are some CRNAs that are just so bad, the bar they have to clear is so low that almost anybody with a pulse can make it through.

Don't get me wrong, there are some great CRNAs out there that do a phenomenal job clinically and could have gone to medical school if they wanted to, but they chose a different path in life and that's fine. They do a good job and know when to call for help or just my opinion. But the worst of the worst are pretty damn bad. And if somebody wants to legislate independent practice, they are telling you that the absolute worst CRNA out there is safe and capable of providing any anesthetic to any patient.

That's when I start laughing at them and fearing for the future of health care in our country.

That is really unfortunate. I know they’re churning out NP’s like they’re plastic bottles or aluminum cans. But at least NPs aren’t dealing with immediate life-and-death situations. They can be f.ing idiots (and a lot of them are) and it won’t make much of a difference. You’d think that anyone dealing with anesthesia would require higher standards.

 

[sevoflurane]

But I'm 100% sure that they care my ACT provides is at least equivalent to an MD only model in terms of patient safety and in several ways superior in terms of patient satisfaction.

"at least"

"several ways superior in terms of patient satisfaction"

OK. How so?

 

[Mman]

As a doctor and specifically a surgeon, I’m sure that’s an accommodation that the anesthesiologists would be willing to make!

Some places, perhaps. At my hospital (nearly 1000 bed level 1 trauma center) it would not be possible. You could ask as nice as you wanted, but as one of my colleagues has told others with this request: "Our practice in this hospital is not set up that way and unfortunately I also have responsibilities to other patients here that I cannot abandon."

 

[Mman]

"at least"

"several ways superior in terms of patient satisfaction"

OK. How so?

I'm drawing a blank on the name of the study, but I'm pretty sure the largest to date was a retrospective review within North Carolina that suggest ACT model had the lowest risk adjusted mortality, although it was not statistically significant compared to MD only within the design of the study.

So it is at least as safe. You'd likely need an N of 1,000,000+ to find a significant safety difference between MD only and ACT model if one existed because the difference would be so small.

As for better in some ways, that's easy.

1) Continuity of care. The same person they talk to in preop is there during induction and is there to trouble shoot problems in PACU.

2) Efficiency. I've already got the epidural placed before the last case is out of the room. I can do the rescue block in PACU (if needed) while the next case is going.

3) I appreciate having another set of eyes looking at the patient that comes from a different training background. They might not be making the ultimate decision on things, but they might catch something I missed. Nobody is perfect and it always helps to have another somebody helping when things aren't going smoothly.

4) Following protocols. RNs seem to be better as a group at following orders than physicians. Things like cleaning the CVP port with alcohol prior to administering any meds through it are good for patient safety, but I'm not as meticulous about it as they are. Keep the IV stopcocks on a clean towel away from the patient to avoid contaminating them. Maintaining contact precautions in the OR. On and on.

 

[proman]

Some places, perhaps. At my hospital (nearly 1000 bed level 1 trauma center) it would not be possible. You could ask as nice as you wanted, but as one of my colleagues has told others with this request: "Our practice in this hospital is not set up that way and unfortunately I also have responsibilities to other patients here that I cannot abandon."

So you're saying that if our ENT friend laid out 20 $100 bills, he couldn't get an attending to do his anesthetic? I understand that it would be impossible on the day of surgery, but you couldn't accommodate him with a little advance notice?

 

[IlDestriero]

As a doctor and specifically a surgeon, I’m sure that’s an accommodation that the anesthesiologists would be willing to make! Besides, there are some cases that are slated to have anesthesiologists (or residents) present from start to finish. So it does happen. But like I said, over my dead body would I allow a CRNA to stand at the head of my bed and make decisions for my health while I’m within an inch of death - which is pretty-much what all anesthesia is. As far as I’m concerned, that’s physician territory. If there are patients that are too dumb to care and are content with a nurse handling it for them, then they have that choice. Again, it’s not acceptable for me.

If you were one of our surgeons and your child was having surgery here, we would likely accommodate your request for a particular anesthesiologist and no trainees or CRNAs. We would not do this for an outside physician. BTW, what people usually request is a specific attending physician and maybe "no residents". Fellows and CRNAs are not normally part of the request. Some parents have requested "no trainees". If we're providing direct care in that room that day, great, no problem, but that's not usually the case. We clearly explain that it is a teaching hospital and that if they want no trainees to be part of their care they need to go somewhere else. Harsh but true. They never leave.

 

[sevoflurane]

The funniest thing to me would be to simply look at their case logs. Look at what kind of cases and how sick the patients were they took care of. The bare minimum requirements to graduate as a CRNA are almost nothing. That's why there are some CRNAs that are just so bad, the bar they have to clear is so low that almost anybody with a pulse can make it through.

But the worst of the worst are pretty damn bad. And if somebody wants to legislate independent practice, they are telling you that the absolute worst CRNA out there is safe and capable of providing any anesthetic to any patient.

That's when I start laughing at them and fearing for the future of health care in our country.

1) Continuity of care means that... continuity.

2) Efficiency is what you do in solo practice. Rescue blocks are done between cases or the board runner/ob guy does them... but usually you.

3) My eyes are all that is needed when I'm in the OR. When my head is in 4 rooms, you can't afford not to have another set of eyes. You need to TRUST in a pair of eyes that aren't trained like yours.

QUOTE=Mman;10584206]

4) Following protocols. RNs seem to be better as a group at following orders than physicians. Things like cleaning the CVP port with alcohol prior to administering any meds through it are good for patient safety, but I'm not as meticulous about it as they are. Keep the IV stopcocks on a clean towel away from the patient to avoid contaminating them. Maintaining contact precautions in the OR. On and on.[/QUOTE]

Dude... really?

 

[FutrrENT]

I'm drawing a blank on the name of the study, but I'm pretty sure the largest to date was a retrospective review within North Carolina that suggest ACT model had the lowest risk adjusted mortality, although it was not statistically significant compared to MD only within the design of the study.

So it is at least as safe. You'd likely need an N of 1,000,000+ to find a significant safety difference between MD only and ACT model if one existed because the difference would be so small.

As for better in some ways, that's easy.

1) Continuity of care. The same person they talk to in preop is there during induction and is there to trouble shoot problems in PACU.

2) Efficiency. I've already got the epidural placed before the last case is out of the room. I can do the rescue block in PACU (if needed) while the next case is going.

3) I appreciate having another set of eyes looking at the patient that comes from a different training background. They might not be making the ultimate decision on things, but they might catch something I missed. Nobody is perfect and it always helps to have another somebody helping when things aren't going smoothly.

4) Following protocols. RNs seem to be better as a group at following orders than physicians. Things like cleaning the CVP port with alcohol prior to administering any meds through it are good for patient safety, but I'm not as meticulous about it as they are. Keep the IV stopcocks on a clean towel away from the patient to avoid contaminating them. Maintaining contact precautions in the OR. On and on.

Since anesthesia isn't my field of medicine, I don't really study the statistics associated with the different arrangements under which it's delivered. I have to say, however, that by claiming that the "anesthesia care team" is as good as the anesthesiologist-only setup, you are making the kind of concession that gives your beloved CRNAs the kind of help and ammunition they need to make claims that they are as good as you.
Just as I'd never, under any circumstance, say that having NP's seeing patients under my supervision is as good as me seeing patients directly (i.e. when I'm an attending), you shouldn't make such statements either. You give these nurses one inch and they'll try to take a mile.
I'm not an anesthesiologist, but I don't think you have to be one to see that having a middle-man like a CRNA is not as good as being under the direct care of the anesthesiologist.

 

[pgg]

That is really unfortunate. I know they’re churning out NP’s like they’re plastic bottles or aluminum cans. But at least NPs aren’t dealing with immediate life-and-death situations. They can be f.ing idiots (and a lot of them are) and it won’t make much of a difference.

I don't know, I bet that NPs hurt more people ... just not acutely. Missed diagnoses, delayed diagnoses, wrong diagnoses, wrong tests, missed tests, delayed referral, inappropriate referral.

I have less faith in primary care midlevels than CRNAs.

 

[Charles_Carmichael]

I don't know, I bet that NPs hurt more people ... just not acutely. Missed diagnoses, delayed diagnoses, wrong diagnoses, wrong tests, missed tests, delayed referral, inappropriate referral.

👍

The problem is that the consequences of this type of malpractice might not manifest until years (decades?) down the road. And at that point, it'd be hard to pinpoint a decision made by a midlevel and successfully argue that they committed malpractice. That's the problem with saying "let midlevels have independence if they want...we'll let the lawyers take care of them." At least, that's my opinion on it (albeit, an opinion based on limited clinical experience).

 

[Idiopathic]

Assuming you worked ~60 hours/week for 48 weeks in any given year, that's less half of the hours earned in one year. This also assumes you were administering anesthesia for all 48 of those weeks.

65 hours per week, across 156 weeks (includes time off, vacation, moonlighting, etc) = 10140 hours at my hospital

4 weeks chronic pain
8 weeks acute pain
16 weeks ICU
1 week periop clinic
12 weeks OB

leaves about 8000 hours scheduled to be in and around the OR. Lets assume that 20% of that is not in the OR = 6000 hours in the operating room

or lets put it this way - i spent more time in the ICU from CA1-3 year than they did learning anesthesia.

 

[Idiopathic]

some of us are believers in the ACT model, especially one that includes residents. this does not translate to a support of CRNA-only independent practice.

 

[jwk]

As a doctor and specifically a surgeon, I'm sure that's an accommodation that the anesthesiologists would be willing to make! Besides, there are some cases that are slated to have anesthesiologists (or residents) present from start to finish. So it does happen. But like I said, over my dead body would I allow a CRNA to stand at the head of my bed and make decisions for my health while I'm within an inch of death - which is pretty-much what all anesthesia is. As far as I'm concerned, that's physician territory. If there are patients that are too dumb to care and are content with a nurse handling it for them, then they have that choice. Again, it's not acceptable for me.

I just love it when non-anesthesia folks come in the anesthesia section and tell all the anesthesia folks how they should do their job. It's like the other thread currently raging with the EM guys about using propofol in the ER.

At the moment, you have a fairly sheltered perspective of how things are in the real world. There are indeed physician-only anesthesia practices out there - and they are few and far between. MOST anesthesia practices, particularly in the larger centers, are going to be ACT type practices with some level of MD supervision or medical direction. The better ones, and I would include mine in that description, have 24/7 in-house anesthesiologist coverage, with an anesthesiologist involved with the care of each and every patient.

My practice has more than 80 AA's and CRNA's and 40 anesthesiologists. Yes, you can have an MD do your anesthesia - as long as you call ahead a week or two. Ours is a heavily medically-directed ACT private practice. We don't have extra people sitting on their asses (unless we're waiting on late surgeons). Each and every MD we have scheduled each day is actually pre-assigned to a specific responsibility within our system months ahead of time. At most you will find two anesthesiologists in OR's doing cases, and on most days there won't be any. That means the other 60 OR's are being covered by anesthetists that are medically directed by an anesthesiologist that is present for induction and emergence and at intervals during the procedure on every single patient. Every patient is seen and examined by an anesthesiologist before every case.

It may not be your preference, but you're welcome to do your cases at a hospital of your choosing, because we wouldn't change our whole practice to accomodate your desires. IlDest, Idiopathic are spot on with their real-world perspectives.

And BTW, the idea of a surgeon paying extra to get an anesthesiologist to do the case is absurd, unprofessional, and unethical IMHO.

Lastly - remember that ENT/plastics are prime users of CRNA-only anesthesia in their private office surgery centers.

 

[altap]

The country needs more MDAs not midlevels. So the gov 't has to increase the # of residency slots but since the gov't does not have the money, residency programs have to offer non salaried residency positions. MDAs will not win this battle unless they do this. Why? Because politics is a numbers game. There are more crnas being churned out by crna schools than mdas being churned out by residency programs. I think you can reverse the trend in a few years if mda orgs do this. This is what industrialized nations do when they lack manpower. When a nation needs engineers it recruits engs from
other countries , it does not train its foremen to do the job of engineers.

 

[IN2B8R]

I'm drawing a blank on the name of the study, but I'm pretty sure the largest to date was a retrospective review within North Carolina that suggest ACT model had the lowest risk adjusted mortality, although it was not statistically significant compared to MD only within the design of the study.

So it is at least as safe. You'd likely need an N of 1,000,000+ to find a significant safety difference between MD only and ACT model if one existed because the difference would be so small.

As for better in some ways, that's easy.

1) Continuity of care. The same person they talk to in preop is there during induction and is there to trouble shoot problems in PACU.

2) Efficiency. I've already got the epidural placed before the last case is out of the room. I can do the rescue block in PACU (if needed) while the next case is going.

3) I appreciate having another set of eyes looking at the patient that comes from a different training background. They might not be making the ultimate decision on things, but they might catch something I missed. Nobody is perfect and it always helps to have another somebody helping when things aren't going smoothly.

4) Following protocols. RNs seem to be better as a group at following orders than physicians. Things like cleaning the CVP port with alcohol prior to administering any meds through it are good for patient safety, but I'm not as meticulous about it as they are. Keep the IV stopcocks on a clean towel away from the patient to avoid contaminating them. Maintaining contact precautions in the OR. On and on.

Funny....Having worked in both models and now doing my own anesthetics (of all types), I cannot agree with any of your points above.🙄

BTW, kuddos to the ENT resident who is posting his honest opinion here. At least he correctly recognizes what is the safest way to deliver/receive an anesthetic....

 

[leaverus]

And BTW, the idea of a surgeon paying extra to get an anesthesiologist to do the case is absurd, unprofessional, and unethical IMHO.

Please explain what you mean by this. How is it any of those three things for a patient to show up for surgery and say "I'm a self-pay patient and i am willing to pay extra to have an anesthesiologist rather than a CRNA take care of me during my surgery"?

 

[Dwindlin]

I just love it when non-anesthesia folks come in the anesthesia section and tell all the anesthesia folks how they should do their job. It's like the other thread currently raging with the EM guys about using propofol in the ER.

Except in that case its Anesthesia trying to tell the guys in the ED how to do their jobs. Sucks right?

And BTW, the idea of a surgeon paying extra to get an anesthesiologist to do the case is absurd, unprofessional, and unethical IMHO.

Why? The patient has the right to dictate who renders their care. I agree with him, no offense I am sure you are great but if I have to go under the knife I want an MD taking care of me.

 

[IlDestriero]

Why? The patient has the right to dictate who renders their care. I agree with him, no offense I am sure you are great but if I have to go under the knife I want an MD taking care of me.

The patient does not have the right to dictate who renders their care. If they want attending only at most hospitals they better be lucky or a VIP, or they will have to pick another facility.
How about residents? Would you guys rather have an attending and a resident care for you or your child or an attending and a 10 yr veteran CRNA?

 

[Idiopathic]

Why? The patient has the right to dictate who renders their care.

Um what?

 

[jwk]

Please explain what you mean by this. How is it any of those three things for a patient to show up for surgery and say "I'm a self-pay patient and i am willing to pay extra to have an anesthesiologist rather than a CRNA take care of me during my surgery"?

So you're saying that if our ENT friend laid out 20 $100 bills, he couldn't get an attending to do his anesthetic? I understand that it would be impossible on the day of surgery, but you couldn't accommodate him with a little advance notice?

The question wasn't about "a patient". And you really think what amounts to offering a bribe is ethical?

And no - if a patient shows up day of surgery asking ONLY for an anesthesiologist, cash in hand or no, we would not accommodate that request. It would have to be arranged in advance.

We don't charge extra for anesthesiologist-only or less for an anesthetist that is medically directed by an anesthesiologist. The fee is what it is, period.

 

[jwk]

Why? The patient has the right to dictate who renders their care. I agree with him, no offense I am sure you are great but if I have to go under the knife I want an MD taking care of me.

Yes, and a practice has the right to utilize it's personnel in the way they see fit. If patient demands and practice policies don't mesh, then the patient is free to go elsewhere. I'm unaware of any all-MD practices in my state, except for individual anesthesiologists who contract with specific hospitals or surgery centers.

Understand that I agree that a patient has a right to request an anesthesiologist personally do their entire case from start to finish. Also understand, that in many practices, either it isn't possible, or it must be arranged in advance. Again - the real world is far different from academia.

 

[Coastie]

The country needs more MDAs not midlevels. So the gov 't has to increase the # of residency slots but since the gov't does not have the money, residency programs have to offer non salaried residency positions. MDAs will not win this battle unless they do this. Why? Because politics is a numbers game. There are more crnas being churned out by crna schools than mdas being churned out by residency programs. I think you can reverse the trend in a few years if mda orgs do this. This is what industrialized nations do when they lack manpower. When a nation needs engineers it recruits engs from
other countries , it does not train its foremans to do the job of engineers.

What's an MDA? Do you mean Physician? Doctor? MD? DO?

MDA is a militant-mursey.org catch-phrase against doctors. Don't use it..and correct those who do.

 

[Coastie]

The patient does not have the right to dictate who renders their care. If they want attending only at most hospitals they better be lucky or a VIP, or they will have to pick another facility.
How about residents? Would you guys rather have an attending and a resident care for you or your child or an attending and a 10 yr veteran CRNA?

Depends on the CRNA and the resident.

If late CA-1 or above, likely the resident. If a senior resident vs CRNA, nearly always the senior resident.

 

[IlDestriero]

Depends on the CRNA and the resident.

If late CA-1 or above, likely the resident. If a senior resident vs CRNA, nearly always the senior resident.

Now they're going to start requesting specific residents as well.
We're drifting pretty badly. SRNAs aren't residents, even if their murse administrators call them residents. Nice try AANA. (Is there a "the finger" smiley?)

 

[proman]

The question wasn't about "a patient". And you really think what amounts to offering a bribe is ethical?

And no - if a patient shows up day of surgery asking ONLY for an anesthesiologist, cash in hand or no, we would not accommodate that request. It would have to be arranged in advance.

We don't charge extra for anesthesiologist-only or less for an anesthetist that is medically directed by an anesthesiologist. The fee is what it is, period.

I have no idea how you consider what my comment referred to as a bribe. I'm just incredulous that several respected attendings on this forum would throw their hands up and say "that's how the practice is run". $2,000 is great remuneration for 1 case in an ASA 1 patient. I hope most practices would consider that a fair sum to assign a patient an attending anesthesiologist. And my scenario had advance notice.

 

[scudrunner]

Funny....Having worked in both models and now doing my own anesthetics (of all types), I cannot agree with any of your points above.🙄

BTW, kuddos to the ENT resident who is posting his honest opinion here. At least he correctly recognizes what is the safest way to deliver/receive an anesthetic....

👍

 

[FutrrENT]

The patient does not have the right to dictate who renders their care. If they want attending only at most hospitals they better be lucky or a VIP, or they will have to pick another facility.
How about residents? Would you guys rather have an attending and a resident care for you or your child or an attending and a 10 yr veteran CRNA?

Honestly? I'll take the resident over the CRNA.

First off, it's an absolute guarantee that the resident knows more medicine than the CRNA. Any of you who don't see the value of that shouldn't be in anesthesiology. And yeah, I'm saying that to a forum full of anesthesiologists and anesthesiology residents!
Second, it's a near certainty that the resident is going to be a more intelligent individual than the CRNA. I know what it takes to get into medical school. I know what it takes to get through medical school. It takes someone who is pretty damn smart. I've also seen the kind of garbage that gets admitted into nursing school. I seriously doubt that CRNA programs weed out the garbage. Even if they do, they're still taking the best of the worst.
Third, if it's a second-year resident, i.e. someone in his first year of anesthesiology, he's going to be watched more closely by the attending than the CRNA would. If he's a third year or fourth year resident, then he already knows more than the CRNA.
If I don't have all the facts, then please feel free to correct me. But I cannot think of a single circumstance where I'd want a CRNA at the head of my bed over an MD/DO.

 

[FutrrENT]

I just love it when non-anesthesia folks come in the anesthesia section and tell all the anesthesia folks how they should do their job. It's like the other thread currently raging with the EM guys about using propofol in the ER.

At the moment, you have a fairly sheltered perspective of how things are in the real world. There are indeed physician-only anesthesia practices out there - and they are few and far between. MOST anesthesia practices, particularly in the larger centers, are going to be ACT type practices with some level of MD supervision or medical direction. The better ones, and I would include mine in that description, have 24/7 in-house anesthesiologist coverage, with an anesthesiologist involved with the care of each and every patient.

My practice has more than 80 AA's and CRNA's and 40 anesthesiologists. Yes, you can have an MD do your anesthesia - as long as you call ahead a week or two. Ours is a heavily medically-directed ACT private practice. We don't have extra people sitting on their asses (unless we're waiting on late surgeons). Each and every MD we have scheduled each day is actually pre-assigned to a specific responsibility within our system months ahead of time. At most you will find two anesthesiologists in OR's doing cases, and on most days there won't be any. That means the other 60 OR's are being covered by anesthetists that are medically directed by an anesthesiologist that is present for induction and emergence and at intervals during the procedure on every single patient. Every patient is seen and examined by an anesthesiologist before every case.

It may not be your preference, but you're welcome to do your cases at a hospital of your choosing, because we wouldn't change our whole practice to accomodate your desires. IlDest, Idiopathic are spot on with their real-world perspectives.

And BTW, the idea of a surgeon paying extra to get an anesthesiologist to do the case is absurd, unprofessional, and unethical IMHO.

Lastly - remember that ENT/plastics are prime users of CRNA-only anesthesia in their private office surgery centers.

Yes. Unfortunately, some ENT's and plastic surgeons are money ****** who are willing to skimp on patient safety. I'm not one of them. I'd work exclusively with anesthesiologists if it were realistically feasible to do so.

 

[bibibi]

The funniest thing to me would be to simply look at their case logs. Look at what kind of cases and how sick the patients were they took care of. The bare minimum requirements to graduate as a CRNA are almost nothing. That's why there are some CRNAs that are just so bad, the bar they have to clear is so low that almost anybody with a pulse can make it through.

Don't get me wrong, there are some great CRNAs out there that do a phenomenal job clinically and could have gone to medical school if they wanted to, but they chose a different path in life and that's fine. They do a good job and know when to call for help or just my opinion. But the worst of the worst are pretty damn bad. And if somebody wants to legislate independent practice, they are telling you that the absolute worst CRNA out there is safe and capable of providing any anesthetic to any patient.

That's when I start laughing at them and fearing for the future of health care in our country.

So according to you the absolute worst MDA out there is safe and capable of providing any anesthetic to any patient? You are talking as if all doctors always do the right things for the patients. I have witnessed many omissions by doctors that resulted in bad patient outcomes. It all comes down to how well you prepared yourself during your training and how much responsibility you are taking for the job that you are doing.

 

[Mman]

So you're saying that if our ENT friend laid out 20 $100 bills, he couldn't get an attending to do his anesthetic? I understand that it would be impossible on the day of surgery, but you couldn't accommodate him with a little advance notice?

Maybe. It'd involve having somebody on vacation come in to do the case and that probably wouldn't be enough $$$.

 

[Mman]

So according to you the absolute worst MDA out there is safe and capable of providing any anesthetic to any patient? You are talking as if all doctors always do the right things for the patients. I have witnessed many omissions by doctors that resulted in bad patient outcomes. It all comes down to how well you prepared yourself during your training and how much responsibility you are taking for the job that you are doing.

They already are. It's called board certified anesthesiologist. That's what that means. I'm not arguing every anesthesiologist is perfect, but I'm arguing that every board certified anesthesiologist is safe, even the worst one.

Let's put the worst anesthesiologist in the country up against the worst CRNA and leave them alone with an ASA 4E patient and see what happens to each.

 

[jwk]

They already are. It's called board certified anesthesiologist. That's what that means. I'm not arguing every anesthesiologist is perfect, but I'm arguing that every board certified anesthesiologist is safe, even the worst one.

Sorry. We're usually on the same page, but that statement is simply incorrect.

 

[Mman]

1) Continuity of care means that... continuity.

2) Efficiency is what you do in solo practice. Rescue blocks are done between cases or the board runner/ob guy does them... but usually you.

3) My eyes are all that is needed when I'm in the OR. When my head is in 4 rooms, you can't afford not to have another set of eyes. You need to TRUST in a pair of eyes that aren't trained like yours.

QUOTE=Mman;10584206]

4) Following protocols. RNs seem to be better as a group at following orders than physicians. Things like cleaning the CVP port with alcohol prior to administering any meds through it are good for patient safety, but I'm not as meticulous about it as they are. Keep the IV stopcocks on a clean towel away from the patient to avoid contaminating them. Maintaining contact precautions in the OR. On and on.

Dude... really?[/QUOTE]


Continuity of care. So when you drop a patient off in the PACU, are you there 30-60 minutes later when there is a problem? Or is it a colleague of yours that is free?

Efficiency. MD only practice will never be as efficient as a well run ACT model. It can't. Our average turnover time in our outpatient surgery center hovers around 8-12 minutes and the ortho patients are all getting blocks preop.

I realize your eyes are all you need. You are obviously perfect and never miss anything. That's wonderful. I'm not perfect. I'm never opposed to having additional information with which to make a decision. That doesn't mean I change my decision, it just means I can have a little bit more information on which to base it.



I realize some people think that that they can do something better than anybody else in the world. It's called confidence. As far as I'm concerned, I'm a Jedi master at anesthesia. I've got the force and I use it routinely to keep people alive and comfortable under my watch.

But I also believe in the ACT model. It makes sense. Me turning the sevo vaporizer from 2 to 3 and dumping the urine every 30 minutes is kind of a waste of my education. If I'm attending in the ICU, I can manage the medical care of 16-20 critically ill patients at once. But if I'm in the OR I can only think about one at a time? Doesn't make sense. I'm smarter than that.

The ACT model is not more dangerous than MD only and definitely has some advantages. Our national society believes it is the way to go, mostly because it works and there will never be enough anesthesiologists to cover every case solo in the US.

 

[jwk]

Continuity of care. So when you drop a patient off in the PACU, are you there 30-60 minutes later when there is a problem? Or is it a colleague of yours that is free?

Efficiency. MD only practice will never be as efficient as a well run ACT model. It can't. Our average turnover time in our outpatient surgery center hovers around 8-12 minutes and the ortho patients are all getting blocks preop.

I realize your eyes are all you need. You are obviously perfect and never miss anything. That's wonderful. I'm not perfect. I'm never opposed to having additional information with which to make a decision. That doesn't mean I change my decision, it just means I can have a little bit more information on which to base it.

I realize some people think that that they can do something better than anybody else in the world. It's called confidence. As far as I'm concerned, I'm a Jedi master at anesthesia. I've got the force and I use it routinely to keep people alive and comfortable under my watch.

But I also believe in the ACT model. It makes sense. Me turning the sevo vaporizer from 2 to 3 and dumping the urine every 30 minutes is kind of a waste of my education. If I'm attending in the ICU, I can manage the medical care of 16-20 critically ill patients at once. But if I'm in the OR I can only think about one at a time? Doesn't make sense. I'm smarter than that.

The ACT model is not more dangerous than MD only and definitely has some advantages. Our national society believes it is the way to go, mostly because it works and there will never be enough anesthesiologists to cover every case solo in the US.

👍👍 There's that real world experience I mentioned previously.

 

[Coastie]

So according to you the absolute worst MDA out there is safe and capable of providing any anesthetic to any patient? You are talking as if all doctors always do the right things for the patients. I have witnessed many omissions by doctors that resulted in bad patient outcomes. It all comes down to how well you prepared yourself during your training and how much responsibility you are taking for the job that you are doing.

Hey, militant-mursey.org troll boy..It comes down to the fact that nurses will always be nurses, and physicians, who have gone through medical school, passed countless boards, and completed residency, will always be doctors.

Doctors practice medicine. Militant-murseys don't know the first thing about practicing medicine. So why do you keep trying to? 😀

 

[IN2B8R]

Dude... really?

Continuity of care. So when you drop a patient off in the PACU, are you there 30-60 minutes later when there is a problem? Or is it a colleague of yours that is free?

There's a floor manager (MD) who is there in case help is needed in PACU and anywhere else peri-operatively: I would trust that person's judgement over that of a CRNA any day. And will you provide that "continuity of care" in the PACU if you are tied down by another 3 rooms? Moreover, are you going to have more PACU "issues" when an MD is running the case vs. a CRNA? I think that it is more often than not to have to respond to a CRNA cared for patient than an MD cared for patient; that has certainly been my real life experience with supervising vs. doing own cases.

Efficiency. MD only practice will never be as efficient as a well run ACT model. It can't. Our average turnover time in our outpatient surgery center hovers around 8-12 minutes and the ortho patients are all getting blocks preop.

Again, I do not understand what you mean by "efficiency": if you have enough bodies in an MD only group, efficieny is not an issue. Every case will get done safer and, potentially, even faster. Is efficiency and getting more cases done for a greater profit more important than a better delivered anesthetic? If so, then don't just stop at supervising only 4 rooms, go ahead and supervise 16 rooms--'cause that would be even more "efficient!"

I realize your eyes are all you need. You are obviously perfect and never miss anything. That's wonderful. I'm not perfect. I'm never opposed to having additional information with which to make a decision. That doesn't mean I change my decision, it just means I can have a little bit more information on which to base it.

Yeah, no one is perfect, particularly if he does not have his eyes on the patient the whole case.... catching a physiologic embarassment early on and being in the room at the very moment it happens is far superior than coming into the room minutes later when the CRNA decides to call you in: try rescuing a PE patient in time before the CRNA recognizes what is happening (happened to me personally).... If you had an MD in the room, your differential would have been helped more readily, i.e., that person would have provided you with the "useful additional information" in a timely manner. Why the MD over the CRNA in such a catestrophic scenario? Simple: his differential and understanding is far superior to that of a CRNA. If you are a member of at least a semi-decent group, then, I hope, that you are more reliant on the judgement of your MDs more than that of your CRNAs.


I realize some people think that that they can do something better than anybody else in the world. It's called confidence. As far as I'm concerned, I'm a Jedi master at anesthesia. I've got the force and I use it routinely to keep people alive and comfortable under my watch.

Good for you, Jedi: you will need the force when a midlevel royally f*cks things up for the patient.

But I also believe in the ACT model. It makes sense. Me turning the sevo vaporizer from 2 to 3 and dumping the urine every 30 minutes is kind of a waste of my education. If I'm attending in the ICU, I can manage the medical care of 16-20 critically ill patients at once. But if I'm in the OR I can only think about one at a time? Doesn't make sense. I'm smarter than that.


Kind of a false analogy here, no? There are many more things that can readily kill a patient in the OR (both surgery and anesthesia wise) than in the ICU.... So, your precious medical education is probably more readily needed in one setting vs. the other....

The ACT model is not more dangerous than MD only and definitely has some advantages. Our national society believes it is the way to go, mostly because it works and there will never be enough anesthesiologists to cover every case solo in the US.[/QUOTE]

Finally, we agree on something: there are not enough anestheiologists around to take care of everyone; therefore, a second best option is needed, that of the ACT model. But let us not mince words here, the ACT model is no where the all MD model when it comes to safety and superior patient peri-operative care.

 

[Arch Guillotti]

Would you guys rather have an attending and a resident care for you or your child or an attending and a 10 yr veteran CRNA?

It doesn't make any difference to me how long a CRNA has been around. I have worked with a couple who have been tubing people since almost before I was alive and they still aren't that good at it. Some CRNA's actually seem to get worse as time progresses. Some of the best ones are the more recent grads.

 

[briggs]

There are many, many extremely skilled CRNAs out there, just as there are many skilled and not-so skilled 'ologists. Remain respectful and learn from everyone, including RNs. There will come a time when a CRNA may save you.

 

[Coastie]

There are many, many extremely skilled CRNAs out there, just as there are many skilled and not-so skilled 'ologists. Remain respectful and learn from everyone, including RNs. There will come a time when a CRNA may save you.

LOL.

First post, we're "ologists", you're an attending, and we should "learn from everyone"?

Do militant-mursey.org troll boys have nothing better to do with their time than make up fake names on SDN and push slurs against physicians?

 

[bibibi]

Hey, militant-mursey.org troll boy..It comes down to the fact that nurses will always be nurses, and physicians, who have gone through medical school, passed countless boards, and completed residency, will always be doctors.

Doctors practice medicine. Militant-murseys don't know the first thing about practicing medicine. So why do you keep trying to? 😀

Well, if that's really what you think then why are you so worried about your profession and that the CRNAs will take over?

Besides, I did not argue that nurses will become physicians at some point of time. The important thing is for everybody to be good at their profession and take patient safety and best outcomes as their first priority, be it MDA or CRNA. In real world a prudent physician will listen to the nurse taking care of his/her patient and a prudent nurse will carry out physician's orders in a timely and exact fashion as long as they are safe and beneficial to the patient.

 

[bibibi]

They already are. It's called board certified anesthesiologist. That's what that means. I'm not arguing every anesthesiologist is perfect, but I'm arguing that every board certified anesthesiologist is safe, even the worst one.

Let's put the worst anesthesiologist in the country up against the worst CRNA and leave them alone with an ASA 4E patient and see what happens to each.

I don't agree that the worst anesthesiologist is safe. I think the worst in any profession is not safe regardless of the amount and time of training. Now if you were to put the worst anesthesiologist against the worst CRNA, in this case, the amount and time of training could make a difference. But I would still prefer to go with average or above average provider be it MDA or CRNA rather than the worst MDA.

 

[altap]

To coastie: Sorry, I didn't know.

 

[Consigliere]

There are many, many extremely skilled CRNAs out there, just as there are many skilled and not-so skilled 'ologists. Remain respectful and learn from everyone, including RNs. There will come a time when a CRNA may save you.

I promise you that when that day comes I will quit medicine. Scram, murse!😡

 

[Farmer2DO]

I'm a bit counfused here. 😕

Anesthesia, as a profession, is trying to stand up against nurse encroachment in their field, as they well should. You guys are beating your chests, yelling that residency trained physicians are the ones that should be administering anesthesia. (Couldn't agree more!) You are screaming about militant nurses providing inferior care, CRNA mills pumping out an inferior product, and how the residency trained physician anesthesiologist should never be replaced by a cheaper product with less education and training. You (as a group) also lament the lack of knowledge by the public who doesn't know the difference between a CRNA and an MD/DO (do most lay people even know what a DO is?), and how they want the cheapest way to do something, not necessarily the best.

Then, when FutrrENT comes on here and says, that as a patient and a future (potential) surgeon he wants to be cared for by, and work with, physicians only, all he gets is how "we can't do it that way". He is even called "absurd, unprofessional, and unethical". But hey, if you're one of our surgeons, we'll accomodate you. How's that for ethics?!?

You actually have someone buying into your argument, and everyone is slapping him down. He's expressing an opinion, and I bet a good part of that comes from reasoning made after reading these boards. So where's the follow through? Someone actually gets educated and tries to make a decision about their care (or the care of others in their care) and they are told "The patient does not have the right to dictate who renders their care." So much for patient involvement and self education.

What gives? 😕

(FWIW, anesthesia is on my short list of fields I am VERY interested in.)

 

[FutrrENT]

LOL.

First post, we're "ologists", you're an attending, and we should "learn from everyone"?

Do militant-mursey.org troll boys have nothing better to do with their time than make up fake names on SDN and push slurs against physicians?

I'll gladly take the title of "ologist" instead of "nurse". I mean, is there anything in this world more pathetic than a male nurse? It's akin to being a man and wearing a badge that says you don't have a penis. There are some professions that aren't intended for men, and nursing is one of them! I hate to break it to the troll who seems to have joined the discussion, but being a male CRNA is still being a nurse.