The ASA needs my wife.

[DocFocker]

I have been reading this forum the past few months and the majority of the content is in someway related to the increase in the role of nursing in the administration of anesthesia. Since I will be an anesthesiologist in a few years I decided to Google "anesthesiologist vs anesthetist" and a number of variations there off. Not one of the Google hits helped to raise awareness of the increasing role of nurses in the administration of anesthesia.

My wife is a public relations professional and could easily come up with a campaign to increase awareness of the changes occurring in our profession. If you asked the average patient the following, Would you rather a doctor or nurse directly control your breathing while you are unconscious during the surgery?, there would be an overwhelming response for the doctor. Why then is the current state of affairs the way it is? What is needed is a legit PR campaign that keeps it simple. The message is simple, nurse or doctor? Doctors of nursing (DNP), are just that, nurses with a doctorate. It's all in the rhetoric. We need to improve our rhetoric, take back control and win the battle.

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[Perrotfish]

If you asked the average patient the following, Would you rather a doctor or nurse directly control your breathing while you are unconscious during the surgery?, there would be an overwhelming response for the doctor. Why then is the current state of affairs the way it is?

If you asked the average patient the following: 'would you rather drive a used mid-sided American sedan or a brand new Ferrari Enzo?', there would be an overwhelming response for the Enzo. If you then asked them why almost all of them in fact bought used American mid-sized sedans, rather than Enzos, they would roll their eyes at you. Because you know just as well as they do that the reason they went with the cheaper option is, in fact, because its cheaper.

People want better products for free. Everyone knows that. To figure which products they actually prefer you need to give them a choice that accurately reflects the cost vs the benefit. Anesthesiologist would need to not only make it clear that they are the better option, but that they are so much better that 'buying' them is worth what the patient loses in money, face time, or whatever. Do you think your wife could effectively make that argument?

 

[Spinach Dip]

If you asked the average patient the following: 'would you rather drive a used mid-sided American sedan or a brand new Ferrari Enzo?', there would be an overwhelming response for the Enzo. If you then asked them why almost all of them in fact bought used American mid-sized sedans, rather than Enzos, they would roll their eyes at you. Because you know just as well as they do that the reason they went with the cheaper option is, in fact, because its cheaper.

Your analogy is weak because Enzos go for about $1mil. That is WAY out of the price range of the average American.... You seem to be implying that on a true open market, no one would pick the MDA option because they wouldn't be able to afford it.

If the difference between having a MDA (no CRNA relief) and CRNA (no MDA oversight) as my provider was $100-200 an hour, I would gladly pay out of my own pocket for the more experienced one.

But, of course, I don't speak for everyone.

 

[nimbus]

Your analogy is weak because Enzos go for about $1mil. That is WAY out of the price range of the average American.... You seem to be implying that on a true open market, no one would pick the MDA option because they wouldn't be able to afford it.

If the difference between having a MDA (no CRNA relief) and CRNA (no MDA oversight) as my provider was $100-200 an hour, I would gladly pay out of my own pocket for the more experienced one.

But, of course, I don't speak for everyone.

When faced with a mountain of other medical bills and income loss due to illness, many Americans will choose the cheapest possible option. Most Americans are not high earning professionals with emergency funds.

 

[NOsaintsfan]

If you asked the average patient the following: 'would you rather drive a used mid-sided American sedan or a brand new Ferrari Enzo?', there would be an overwhelming response for the Enzo. If you then asked them why almost all of them in fact bought used American mid-sized sedans, rather than Enzos, they would roll their eyes at you. Because you know just as well as they do that the reason they went with the cheaper option is, in fact, because its cheaper.

People want better products for free. Everyone knows that. To figure which products they actually prefer you need to give them a choice that accurately reflects the cost vs the benefit. Anesthesiologist would need to not only make it clear that they are the better option, but that they are so much better that 'buying' them is worth what the patient loses in money, face time, or whatever. Do you think your wife could effectively make that argument?

I agree with the above but that's not the whole story.

The majority of Americans getting anesthesia services are "paying" with insurance. Obviously not everyone falls into that boat but most do. If you have insurance all your paying is your deductible and the bottom line is to that particular patient the amount they will pay out of pocket is the same either way. CRNA's are not cheaper for the patient. They are only cheaper for the hospital. If the money to the patient is essentially the same why not get the best?

 

[deleted162650]

Exactly. The anesthesia fee is the same regardless if it's MD only, ACT, or independent CRNA. No reason for the patient to not opt for MD only Anesthesia. Now if you are the hospital directly employing independent CRNA's and pocketing the difference it's a different story.

 

[Ronin786]

Your analogy is weak because Enzos go for about $1mil. That is WAY out of the price range of the average American.... You seem to be implying that on a true open market, no one would pick the MDA option because they wouldn't be able to afford it.

If the difference between having a MDA (no CRNA relief) and CRNA (no MDA oversight) as my provider was $100-200 an hour, I would gladly pay out of my own pocket for the more experienced one.

But, of course, I don't speak for everyone.

Why do you insist on using the term MDA? It's a generally demeaning term when referring to an anesthesiologist.

It's a term used to make MDs look closer like CRNAs.

 

[Stank811]

So really the analogy should be for the same price do you want an enzo or a mid size american sedan…..

 

[007livesforever]

This would be a self mutilating strategy for a number of reasons, the first being is that most groups are care team and most use crnas or aa's. You think that they are going to go on board saying they render substandered service?
Secondly the ASA has been touting the efficacy saftey and quality of the care team for the ladt 20 years, going to require a lot of double think to get around that.

 

[Stank811]

OO7 I agree with the above if you were comparing ACT to independent physician….but that isn't the game anymore….it is hospital wanting to use CRNA independently

 

[Cytarabine]

Exactly. The anesthesia fee is the same regardless if it's MD only, ACT, or independent CRNA. No reason for the patient to not opt for MD only Anesthesia. Now if you are the hospital directly employing independent CRNA's and pocketing the difference it's a different story.

Why MD only? If I'm not mistaken, an oft-cited ASA-funded study found superior outcomes for the ACT model (with MD only trailing and then CRNA falling below that)

 

[DocFocker]

People don't know what they are getting much less what they are paying for. That's my point.

 

[Noyac]

Why MD only? If I'm not mistaken, an oft-cited ASA-funded study found superior outcomes for the ACT model (with MD only trailing and then CRNA falling below that)

I need to see this article. There is no F'in way the ACT model is better than a physician only model. I have worked in both. My ACT group was top notch and taught me an enormous amount but we had to greatly restrict the crna cases due to the acuity of care needed at times. I am now in a physician only practice and it is light years better. Yes, there were some better physicians in my ACT group but they were spread across a few nurses and therefore, had to rely on the nurses to perform well. Currently, I can say our overall pt care is much better.

 

[Noyac]

Btw, crna vs MD cost is the same to the pt.
Why the ASA doesn't do a public relations campaign on this is beyond me. Personally I think they may be afraid of the repercussions of the militant nurses. This is why we need new leadership in the ASA. People with the balls to address this issue.

 

[Cytarabine]

I need to see this article. There is no F'in way the ACT model is better than a physician only model. I have worked in both. My ACT group was top notch and taught me an enormous amount but we had to greatly restrict the crna cases due to the acuity of care needed at times. I am now in a physician only practice and it is light years better. Yes, there were some better physicians in my ACT group but they were spread across a few nurses and therefore, had to rely on the nurses to perform well. Currently, I can say our overall pt care is much better.

I'll see if i can dig it up either today or tomorrow. I haven't looked at it in a couple years, but I don't think my memory is failing me. It's been referenced on this board before to counter independent CRNA practice

Edit: to be clear, i believe the article included physician-resident teams as part of the ACT model. Anyway, I'll see if i can find it when i get the chance

 

[Spinach Dip]

Why do you insist on using the term MDA? It's a generally demeaning term when referring to an anesthesiologist.

It's a term used to make MDs look closer like CRNAs.

Because the fear that anesthesiologists have for those 3 letters is borderline stupid.

Want to take the AANA head-on? Want to show them that this war of words is meaningless? Accept their silly little title and flaunt it like you came up with it yourself.

Don't let their politically-motivated terminology have power over you.

 

[Spinach Dip]

Most Americans are not high earning professionals with emergency funds.

I'm a poor-ass grad student who has to pay my medical bills with student loans. The amount of cash I have on hand is negligible.

Regardless, I would find a way to pay that extra $100-200 dollars an hour if it meant getting the best care possible.



Which bring me to another point. If patients aren't convinced by safety records and levels of training, you can always play the customer service angle... ie. "Less of our patients have post-op nausea!" or "Pain control is our first priority!"

Customer service. It's the way most businesses attract repeat customers. In fact, there was a thread a couple days ago about how hospital food can be a major draw. It sounds stupid, but remember that most Americans ARE stupid. Play to that.



Honestly, if someone was expecting a regional anesthetic, and they wake up coughing blood (presumably from a poorly placed ET tube), there should AT LEAST be a note from the anesthesiologist/surgeon explaining in brief what complications occurred, why the tube was placed, and why the patient is now coughing up blood. A little bit of an apology would be nice also.

And if a patient spends 3 minutes pre-op explaining that they have GERD, PONV, and are terrified of aspirating their own stomach acid, the correct response is not to give 2 mg Zofran as they are waking up, followed by running of the room as they start retching with the attitude of "he's awake now, so it's not my problem." (that was a CRNA who relieved the MDA half-way through the procedure, so I'm not sure if it was a breakdown of communication or if one of them failed hard....)

Customer Service.

 

[Mman]

I need to see this article. There is no F'in way the ACT model is better than a physician only model. I have worked in both. My ACT group was top notch and taught me an enormous amount but we had to greatly restrict the crna cases due to the acuity of care needed at times. I am now in a physician only practice and it is light years better. Yes, there were some better physicians in my ACT group but they were spread across a few nurses and therefore, had to rely on the nurses to perform well. Currently, I can say our overall pt care is much better.

Because your N of 1 or 2 is relevant for making a statement that would probably need a study with 1,000,000+ patients to detect a difference in quality. I mean I've seen some MD only practices that were bad with some real weak links and you can't hide them in any way in that setting.

If you do a risk adjusted study of MD only vs ACT model, the chances of you finding a significant benefit to the MD only model is beyond miniscule. Now if you could restrict your study to only ASA 4-5 patients having major surgery, then you might be able to show a small difference over only thousands of patients, but that's about it and I'm not even sure you could show that.

 

[24858]

I need to see this article. There is no F'in way the ACT model is better than a physician only model. I have worked in both. My ACT group was top notch and taught me an enormous amount but we had to greatly restrict the crna cases due to the acuity of care needed at times. I am now in a physician only practice and it is light years better. Yes, there were some better physicians in my ACT group but they were spread across a few nurses and therefore, had to rely on the nurses to perform well. Currently, I can say our overall pt care is much better.

i agree, been in both situations, and same experience

 

[Noyac]

Because your N of 1 or 2 is relevant for making a statement that would probably need a study with 1,000,000+ patients to detect a difference in quality. I mean I've seen some MD only practices that were bad with some real weak links and you can't hide them in any way in that setting.

If you do a risk adjusted study of MD only vs ACT model, the chances of you finding a significant benefit to the MD only model is beyond miniscule. Now if you could restrict your study to only ASA 4-5 patients having major surgery, then you might be able to show a small difference over only thousands of patients, but that's about it and I'm not even sure you could show that.

This coming from someone making a boat load of money off nurse anesthesia. Ok, Mman, I believe you. There is no difference.

 

[DocFocker]

So I posted this thread yesterday and serendipitously I'm sitting there today studying Miller and a pilot friend of mine approaches me. He asks, "So doc what's the difference between an anesthesiologist and a nurse anesthetist?" I smiled and explained that anesthesiologists are the authority on the administration of anesthesia and that nurses (CRNAs) are typically supervised by doctors.
He had no idea of the different roles nurses and doctors played in the administration of anesthesia. This lack of general knowledge is our public relations failure. Nurses obviously have their role and will continue to. However, we have failed miserably in the PR game.

 

[Cytarabine]

http://mobile.journals.lww.com/anes...ewer.aspx?year=1996&issue=06000&article=00030

That isn't the article I've previously read, but it shares similar results (haven't read it all, only skimmed). I can't seem to find it. Cited it in an unpublished paper I wrote in 2010 or 2011, maybe if I can find that I can find the article. Regardless, in looking, I came across several more recent studies / literature reviews saying that >1 million anesthesia encounters would be needed for sufficient power to look at outcomes

 

[Cytarabine]

So I posted this thread yesterday and serendipitously I'm sitting there today studying Miller and a pilot friend of mine approaches me. He asks, "So doc what's the difference between an anesthesiologist and a nurse anesthetist?" I smiled and explained that anesthesiologists are the authority on the administration of anesthesia and that nurses (CRNAs) are typically supervised by doctors.
He had no idea of the different roles nurses and doctors played in the administration of anesthesia. This lack of general knowledge is our public relations failure. Nurses obviously have their role and will continue to. However, we have failed miserably in the PR game.

I've spoken with physicians previously about the lack of physician-led outcome comparison studies between APN's and physicians, and the general consensus I've received is a desire to avoid alienating nurse colleagues

 

[Consigliere]

The ASA doesn't need your wife, the ASA needs to grow a set of balls.

 

[MaximusD]

THE PUBLIC DOESN'T CARE ABOUT STUDIES. They care about marketing, and therefore so should we. You are assuming that the general public is science-minded and typically thinks "show me the data/proof". That is not the case. Most patients *know* that doctors are better-trained, but what they fail to realize is that the anesthetist-anesthesiologist dichotomy is significant, and in many cases they fail to recognize that an anesthetist is a nurse and an anesthesiologist is a physician. It is truly that simple.

 

[Perrotfish]

Your analogy is weak because Enzos go for about $1mil. That is WAY out of the price range of the average American.... You seem to be implying that on a true open market, no one would pick the MDA option because they wouldn't be able to afford it.

If the difference between having a MDA (no CRNA relief) and CRNA (no MDA oversight) as my provider was $100-200 an hour, I would gladly pay out of my own pocket for the more experienced one.

But, of course, I don't speak for everyone.

I would too. Of course I'm doing better than most American households and I've always valued healthcare much more highly than most people, which I think is similar to most physicians. I think healthcare industry is a lot like the airline industry: the business side of the house has realized that, at the end of the day, price point is a much bigger driver for their customers than differences in the quality of service, because they have a hard time perceiving the difference in quality of service. Higher income clients who also perceive a difference in quality are the exception, not the rule.

Actually a better analogy than the sedan/enzo thing might be car safety ratings. You don't need to drive an enzo to be willing to shell out for a 5 star safety rating, but most people won't pay the extra 10-20K for that kind of safety rating. Its a risk, with their lives. However they weigh the options and still feel that the risk is very minor and that the money can go to things the want/need more. So is anesthesiologist care a 5 star safety rating (luxury safety) or is it more like having a gas tank that doesn't explode at random (bare minimum safety)? Or is there really an improved outcome at all? If you don't have the studies to show a significantly improved outcome with MD care then I'm not sure how much the OP's wife would have to work with.

 

[Perrotfish]

Exactly. The anesthesia fee is the same regardless if it's MD only, ACT, or independent CRNA. No reason for the patient to not opt for MD only Anesthesia. Now if you are the hospital directly employing independent CRNA's and pocketing the difference it's a different story.

This is and isn't true. When costs are bundled together its true that you end up paying the 'same' fee for both a higher and lower quality of service. However the overall cost of the service is driven down by an organization that controls overhead. The organization that is 90% independent CRNAs might charge the same nominal anesthesia fee for an MD and a CRNA, but their fee is likely an average of the costs of the MD and CRNA care they proviede and is therefore lower than the 100% MD practice. When customers select primarily for a better price point, they push whoever is selling to cost cut. When they don't complain about a specific cost cutting measure (like MD vs CRNA care) then the organization assumes the cost saving measure was a good one. The customers 'choose' the cheaper anethesia option by choosing the overall cheaper provider.

 

[Mman]

This coming from someone making a boat load of money off nurse anesthesia. Ok, Mman, I believe you. There is no difference.

Spoken like a true scientist. Your anecdotal tale and personal distate are truly a way to make an informed decision. Congrats. I hope for your patient's sake that you base clinical decisions on higher levels of evidence. And for the record I do locums work in MD only model so I have experience in both.

 

[wjs010]

Wtf. You guys are called MDA now? In the words of bill maher, people should be more cynical about the ads they watch. Marketing should not have the power over people that it does. But it actually does. So the ASA needs to market better to get the message into people's heads. They don't care about science. They care about beautiful ads.

Why does the ASA not have powerful marketing? Is it because they didn't feel the need to market, since they aren't insecure about their qualifications in caring for patients? I'm really curious about that.

 

[24858]

This is and isn't true. When costs are bundled together its true that you end up paying the 'same' fee for both a higher and lower quality of service. However the overall cost of the service is driven down by an organization that controls overhead. The organization that is 90% independent CRNAs might charge the same nominal anesthesia fee for an MD and a CRNA, but their fee is likely an average of the costs of the MD and CRNA care they proviede and is therefore lower than the 100% MD practice. When customers select primarily for a better price point, they push whoever is selling to cost cut. When they don't complain about a specific cost cutting measure (like MD vs CRNA care) then the organization assumes the cost saving measure was a good one. The customers 'choose' the cheaper anethesia option by choosing the overall cheaper provider.

have you ever billed for anesthetic care? the rates are negotiated with, usually a physician organization in the hospital with each individual insurance company, they are paid to get you higher per unit fees. do you think this organization, especially if the anesthesia team are hospital employees, is going to negotiate a lower fee, regardless is the team is md or crna? of course they are going to negotiate the highest per unit fee possible period, now the hospital may choose to pay the crnas less and pocket the difference, but to suggest the hospital is going to push for lower per unit fees simply because they employee crnas is simply not true.
customers don't select based on price points, perhaps in the future.
hospitals may push for independent crnas because it will help them make more money as they can pocket more the billed anesthesia charges. however what most hospitals will find out is that poor quality is not always economical long term.
lawyers can be our friend and saviors

 

[Noyac]

Yes Mman, you are a true steward of our profession.

 

[ProfessorKhan]

Honestly, if the nurses can do it, why not let them? I don't see what the issue is. Doctors aren't really that different from nurses, they just have a little more schooling.

 

[BuzzPhreed]

Honestly, if the nurses can do it, why not let them? I don't see what the issue is. Doctors aren't really that different from nurses, they just have a little more schooling.

 

[Baller MD]

Honestly, if the nurses can do it, why not let them? I don't see what the issue is. Doctors aren't really that different from nurses, they just have a little more schooling.

The problem is, they can't do it SAFELY without having physicians bailing them out. Yeah, we have more schooling than them. We also would've ****ted on their classes and got drunk every night and still be able to pass their classes.

 

[ProfessorKhan]

The problem is, they can't do it SAFELY without having physicians bailing them out. Yeah, we have more schooling than them. We also would've ****ted on their classes and got drunk every night and still be able to pass their classes.

Yeah, I guess. Really though, all that is is your opinion.

 

[Baller MD]

Yeah, I guess. Really though, all that is is your opinion.

And that is your opinion too. Except mine has more validity. Come back when you're actually in med school.

 

[ProfessorKhan]

And that is your opinion too. Except mine has more validity. Come back when you're actually in med school.

I'm an attending. So my opinion has more validity. Your opinion means nothing compared to mine.

 

[BuzzPhreed]

Dude, don't take the bait.

 

[BuzzPhreed]

And that is your opinion too. Except mine has more validity. Come back when you're actually in med school.

C'mon Baller. Obviously this idiot is only trolling here. Best ignored.

 

[24858]

Honestly, if the nurses can do it, why not let them? I don't see what the issue is. Doctors aren't really that different from nurses, they just have a little more schooling.

professorkhan, the ability to do more is from more schooling. i have been schooled to do everything with a lot more hours than any nurse. case in point, to graduate from residency an anesthesiologist has to independently perform roughly 200 neuraxially anesthetics, this allows the individual to see complications and work through how to treat the complications. a crna has to do 30 neuraxials and those aren't independent, those can be observation. with such lower numbers the ability to see complications is much less and therefore to know how to respond appropriately without harming the patient physically.
the wide ranging surgical procedures available are now being performed on much sicker patients and at the extremes of age, which increases physiological variability and potential for harm that much greater with much smaller changes in physiologic insult. anesthesia care has been advanced by anesthesiologists to the point of great safety for all, now these changes are advantageous for society at large because it has allowed us to perform a ever widening array of surgical procedures safely.
now to ask society to lay this foundation at the hands of ill equipped and ill prepared individuals at the immediate, perhaps, savings in cost, seems in my mind, short sighted. would you be ok with this same scenario in other fields? how about the individuals taking care of our nuclear reactors? is just ok good enough? how about the flight engineers? is just ok good enough? when will it not be good enough? when you and your family are in a 747 and you suddenly realize that the plan is being flown by an ill prepared pilot and an ill prepared flight engineer?
when is good enough good enough? you tell me? do you want to go into surgery with the confidence that you will be in the most skilled hands that society can offer? or do want to be in the hands of someone, who is not vetted? may not understand physiology, doenst have the knowledge or experience to save your live during a critical incident? its a societal question, its a personal question. if society doesn't care about the care provided to them and their loved ones and wants to go with the walmart answer across all levels of medicine, then that is what you will be provided with. why would anyone go to medical school? long hours of study, sacrifice and dedication and only to be compensated the same as someone who went to a community college nursing program was accepted without rigorous examination or vetting process into a crna, pa, or np program and has many deficiencies in knowledge, skill and character. thats the reality. you get the service and the quality you pay for.

 

[BuzzPhreed]

MeaCulpa don't encourage it. Trolls like to be fed.

 

[24858]

Honestly, if the nurses can do it, why not let them? I don't see what the issue is. Doctors aren't really that different from nurses, they just have a little more schooling.

just to add to that. i may be able to do anything and everything in the anesthesia world, but i am expert in a smaller area and feel ultimately confident in that arena, i would recommend a hospital or colleague to take care of certain areas of anesthesia. that is a major difference between anesthesiologists and crnas, anesthesiologists look at a situation and think i am the best option or maybe this would be better in the hands of one of my partners, case in point pediatric hearts, i would defer to a partner, there are a number of examples. if its an emergency then of course i will perform to the best of my abilities. but crnas are taught to go into everything like they know everything. putting your life or your loved ones life in jeopardy, there is no self awareness no humility no respect for what they don't know.

 

[24858]

MeaCulpa don't encourage it. Trolls like to be fed.

my bad. sorry, didn't realize

 

[Baller MD]

I'm an attending. So my opinion has more validity. Your opinion means nothing compared to mine.

Maybe in your dreams bro.

 

[Mman]

Yes Mman, you are a true steward of our profession.

So you aren't a fan of advocating for physician lead care? You don't like people who make political contributions to grease the wheels in our favor?

Or are you just whiny that I and the best available research on the topic disagree with you?

 

[Noyac]

So you aren't a fan of advocating for physician lead care? You don't like people who make political contributions to grease the wheels in our favor?

Or are you just whiny that I and the best available research on the topic disagree with you?

What are you talking about?

Look, Im not gonna argue back and forth with you here. The vast majority of people here would rather work in an all MD/DO group than an ACT group. I know you understand why the ASA has chosen to back the ACT model and i dont disagree with them on that front. But i dont believe they are better. And neither do the majority of our SDN members reading this.

 

[scudrunner]

Honestly, if the nurses can do it, why not let them? I don't see what the issue is. Doctors aren't really that different from nurses, they just have a little more schooling.

Yeah, that's the argument of the nurses. As a physician/scientist you should be asking if they can do all cases safely without supervision. You could train a monkey to do a GA on an ASA 1, but that doesn't mean they can handle the unexpected complications much less a GA on an ASA 3/4 and their complications or avoid the delayed morbidities a bad anesthetic will incur. You and your line of illogic are the reason this specialty faces it's current challenges.

 

[Spinach Dip]

Found this post in another thread:

Still, my favorite bad CRNA move of all time is the "move the ECG leads around to make the ST depression go away" stunt.

My God.



This is the kind of thing that needs to be publicized. People need to know that there ARE unsafe crnas out there and that they HAVE a choice.

I'm thinking a documentary like "Fast Food Nation". We can call it "Bad Medicine" or something....

 

[wjs010]

there's probably tons of documentaries of terrible docs out there, of course highlighting their super duper salaries as well. There should be a doc about CRNA's.

Found this post in another thread:





My God.



This is the kind of thing that needs to be publicized. People need to know that there ARE unsafe crnas out there and that they HAVE a choice.

I'm thinking a documentary like "Fast Food Nation". We can call it "Bad Medicine" or something....