The gall of the CRNAs

[Ducttape]

I just got this email that apparently was sent out to the CRNAs.

it almost looks like they plan on interrupting the ASA meeting.

Dear XXX:

If there is a time when we need you to reach out to your elected officials in support of CRNA pain care, then that time is now!
This very week, Oct. 13-17, members of the American Society of Anesthesiologists will come to Washington, D.C., to take part in their Annual Meeting and conduct Capitol Hill visits.
Incidentally, we have learned that Congressman Paul Broun MD (R-GA) is asking his fellow members of the House of Representatives to join him in sending a "Dear Colleague" letter to the Medicare Agency in strong opposition to CRNA pain management services.
Coincidence? We don't think so either.
This set of events is happening on top of 13 members of the House Doctors Caucus and news publications making inaccurate and misleading statements about CRNA pain care over the last few weeks.
It goes without saying that we must make our voice heard -- now!
Please take the time to visit ProtectmyPainCare.com, click on the "Take Action" button, and use the tools to locate your elected official and CALL OR WRITE them and ask that THEY NOT sign on to Congressman Broun's inaccurate letter full of misleading and untrue statements.
We showed our adversaries that we are a force during the pain care public comment period. Let's remind them of that fact by contacting our elected officials - in force - and ask they support Medicare patients, their constituents and our profession by supporting CRNA pain care and opposing Rep. Broun's letter.
Sincerely,


Janice Izlar, CRNA, DNAP
President

---

Members don't see this ad.

 

[clubdeac]

 

[SSdoc33]

obviously, the CRNAs are ridiculous, but Paul Broun is not the guy to lead the charge.... even if he is an MD.


http://www.latimes.com/news/nation/...broun-evolution-hell-20121007,0,4628858.story

 

[lonelobo]

obviously, the CRNAs are ridiculous, but Paul Broun is not the guy to lead the charge.... even if he is an MD.


http://www.latimes.com/news/nation/...broun-evolution-hell-20121007,0,4628858.story

Well I am usaully the biggest Anti- (Jesus Freak/ Creationist/nutjob) person around,
but if he helps squash the CRNAs- Bring me a large glass of the Kool-aid, and new version
of King James

 

[specepic]

http://www.protectmypaincare.com/wsj

See, it wont actually worsen the opioid crisis b/c CRNAs plan to just be needle jockey's and not RX narcs! Problem solved!

I actually used the protectmypaincare link to send my own emails to congress, I just changed the subject and body of the email.

 

[painstop]

That letter shows you how out of touch these idiots are with the field. All of pain can be cured with an interlaminar epidural (or maybe a TF or facet injection if they went to a weekend course). The whole thing just blows my mind.

 

[seamonkey]

Rep Broun juxtaposes the two things I probably have the strongest feelings about......
There's gotta be somebody else who can carry the standard for us without dismissing the basic tenets upon which our profession is founded (the scientific method). Sheesh.

 

[Jcm800]

http://www.protectmypaincare.com/wsj

See, it wont actually worsen the opioid crisis b/c CRNAs plan to just be needle jockey's and not RX narcs! Problem solved!

I actually used the protectmypaincare link to send my own emails to congress, I just changed the subject and body of the email.

They are a sly bunch are they not...

 

[hyperalgesia]

I was just looking at the CRNA's website and claims of "public support" in their role as pain providers. Looking at their survey and interpretation, it's no wonder they didn't get into med school.

Survey question: "Do you agree with this statement:
'patients should have the ability to visit a nurse anesthetist or other licensed health professionals of their choosing to keep treatment accessible and affordable.' ?"

From this, the CRNAs inferred:

​

"Huge majorities say they are comfortable with receiving care from a CRNA, favor Medicare continuing to cover pain care services provided by CRNAs, and believe it is important that patients should have the ability to visit a CRNA or other licensed health professionals of their choosing."

Talk about putting words in the mouth!

 

[jsaul]

crna today told me while she was giving iv sedation on my rfa case that her crna friend went to a course to learn rfa and now will be doing them. She then said "i watched you do them 3 times now and bet I could do it too."

 

[bedrock]

crna today told me while she was giving iv sedation on my rfa case that her crna friend went to a course to learn rfa and now will be doing them. She then said "i watched you do them 3 times now and bet I could do it too."

This is why you don't even hire the CRNA to do sedation on pain cases

 

[jsaul]

This is why you don't even hire the CRNA to do sedation on pain cases

i didn't. the MD anesthesia group that services the surgery center did

 

[W222]

crna today told me while she was giving iv sedation on my rfa case that her crna friend went to a course to learn rfa and now will be doing them. She then said "i watched you do them 3 times now and bet I could do it too."

You should have dropped the needle right there and took her up on the challenge. Or better yet, ask all the patients next time if they want someone who took the three day course or the five year track.

 

[deleted185747]

Is this correct?

PA = PA works under the MD, initial eval is done by MD, follow ups are done by the PA, if malpractice is awarded then both are penalized.

NP = works independently, if malpractice awarded then NP is penalized. Patient is not seen by MD. Does not perform epidurals.

CRNA = works independently, if malpractice awarded then CRNA is penalized. Patient is not seen by MD. Tries to perform epidurals but not trained to do them according to the standard of care.

 

[Ducttape]

Is this correct?

PA = PA works under the MD, initial eval is done by MD, follow ups are done by the PA, if malpractice is awarded then both are penalized.

NP = works independently, if malpractice awarded then NP is penalized. Patient is not seen by MD. Does not perform epidurals.

CRNA = works independently, if malpractice awarded then CRNA is penalized. Patient is not seen by MD. Tries to perform epidurals but not trained to do them according to the standard of care.

there is interstate variance.

there is a collaborating physician for NPs and, in some states, supervising anesthesiologists for CRNAs. essentially, if a doctor can be sued, he will.

 

[PikminOC]

there is interstate variance.

there is a collaborating physician for NPs and, in some states, supervising anesthesiologists for CRNAs. essentially, if a doctor can be sued, he will.

Yup. I love how it is called "collaboration".

 

[bedrock]

i didn't. the MD anesthesia group that services the surgery center did

Are you doing MAC for an RF?

Simple solution is do just do IV sedation with an RN when you think the patient needs it, but skip the CRNA on all your cases.

 

[specepic]

Is this correct?

PA = PA works under the MD, initial eval is done by MD, follow ups are done by the PA, if malpractice is awarded then both are penalized.

NP = works independently, if malpractice awarded then NP is penalized. Patient is not seen by MD. Does not perform epidurals.

CRNA = works independently, if malpractice awarded then CRNA is penalized. Patient is not seen by MD. Tries to perform epidurals but not trained to do them according to the standard of care.

No, the big pain group in my state has their PAs often do the first visit, the injection, the follow ups. They have an army of PAs, CRNAs, NPs, and only a few MDs for about 10 office locations.

 

[W222]

No, the big pain group in my state has their PAs often do the first visit, the injection, the follow ups. They have an army of PAs, CRNAs, NPs, and only a few MDs for about 10 office locations.

Let me guess, you are in New Hampshire? I have seen a group like this there.

 

[rexed]

http://www.painmd.com/our-providers/greg-aprilliano-crna-msna-aprn.html

There are several CRNA's at this practice. Stims & Vertebroplasty? I like how they list their history working as an RN, then CRNA doing hearts, peds, etc OR. Then all the sudden they're qualified to perform interventional pain...Vertebroplasty? Really? I'm sure the MD's at that practice agree that their CRNA counterparts are equally qualified as they are.

 

[cbrons]

there is interstate variance.

there is a collaborating physician for NPs and, in some states, supervising anesthesiologists for CRNAs. essentially, if a doctor can be sued, he will.

This is strange. "Collaborating." Walgreens prescription bottles and so far as I know databases in general have a section that says "supervising physician." What the heck is a collaborator?

 

[Aether2000]

To ensure initial control over NPs and acceptance, the boards of nursing accepted the need for a collaborating physician. Most states have maintained this requirement even though the collaborating physician requirements are effectively to review a random sample of the NP's charts, and not be required to participate in any active patient care decisions. Some NPs work hundreds of miles away from their collaborating physicians and these physicians need not be of the same specialty of patients seen by the NP. Effectively, it is completely independent practice of NPs with perfunctory and cursory "supervision" based on whatever charts the NP sends the doctor to review. In our state it is 5% of the charts. Indeed, physicians have been drawn into litigation due to NPs ineptitude and simply because they have a reviewer's relationship only with the NP. It would be akin to suing the state medical board for lack of supervision of physicians, yet in the real world of topsy turvy legal gambits, it actually works in the realm of the NP-physician collaboration.

 

[Ducttape]

to expound, it also actually works (well) for the NP.

like algos states, the physician may have little to no control over the NP's actions, unless the physician sets the precedent of monitoring and reviewing the NPs work on a nearly constant basis. if the physician is willing, the physician will act not unlike a parent watching a child and things go very smoothly. unfortunately, it is extraordinarily easy to let things slide and then, essentially, the NP is pretty much independent and can follow his/her own agenda...

 

[PikminOC]

To ensure initial control over NPs and acceptance, the boards of nursing accepted the need for a collaborating physician. Most states have maintained this requirement even though the collaborating physician requirements are effectively to review a random sample of the NP's charts, and not be required to participate in any active patient care decisions. Some NPs work hundreds of miles away from their collaborating physicians and these physicians need not be of the same specialty of patients seen by the NP. Effectively, it is completely independent practice of NPs with perfunctory and cursory "supervision" based on whatever charts the NP sends the doctor to review. In our state it is 5% of the charts. Indeed, physicians have been drawn into litigation due to NPs ineptitude and simply because they have a reviewer's relationship only with the NP. It would be akin to suing the state medical board for lack of supervision of physicians, yet in the real world of topsy turvy legal gambits, it actually works in the realm of the NP-physician collaboration.

That is why I refuse to "collaborate". Ha!

 

[PikminOC]

to expound, it also actually works (well) for the NP.

like algos states, the physician may have little to no control over the NP's actions, unless the physician sets the precedent of monitoring and reviewing the NPs work on a nearly constant basis. if the physician is willing, the physician will act not unlike a parent watching a child and things go very smoothly. unfortunately, it is extraordinarily easy to let things slide and then, essentially, the NP is pretty much independent and can follow his/her own agenda...[/QUOTE]


Until there is a lawsuit....then the NP will relegate all her "expertise" to the collaborating physician. How do you make money off an NP if you need to micromanage anyway?

 

[Ducttape]

to expound, it also actually works (well) for the NP.

like algos states, the physician may have little to no control over the NP's actions, unless the physician sets the precedent of monitoring and reviewing the NPs work on a nearly constant basis. if the physician is willing, the physician will act not unlike a parent watching a child and things go very smoothly. unfortunately, it is extraordinarily easy to let things slide and then, essentially, the NP is pretty much independent and can follow his/her own agenda...[/QUOTE]


Until there is a lawsuit....then the NP will relegate all her "expertise" to the collaborating physician. How do you make money off an NP if you need to micromanage anyway?

you dont "make money off an NP". You train them to work with you, to run by those very vital decisions with you so that you two are on the same page. the midlevel provider, whether NP or PA, sees patients in follow up, helps see medical management patients, follows those patients that require primary physical therapy/behavioral medicine therapy, allowing the physician to focus om those procedures that are more likely to generate income, such as procedures and reduces time spent with new patients.

the key "making money" is to make the physician more efficient and focused more on money generating aspects of care.

 

[lobelsteve]

you dont "make money off an NP". You train them to work with you, to run by those very vital decisions with you so that you two are on the same page. the midlevel provider, whether NP or PA, sees patients in follow up, helps see medical management patients, follows those patients that require primary physical therapy/behavioral medicine therapy, allowing the physician to focus om those procedures that are more likely to generate income, such as procedures and reduces time spent with new patients.

the key "making money" is to make the physician more efficient and focused more on money generating aspects of care.

Am I misreading or is the point to just make money at the expense of opiate monitoring and adequate DX of new patients? Or are you saying your NP is as good as you at evals. Either way not good. I see no role for mid levels in our field.

 

[Ducttape]

Am I misreading or is the point to just make money at the expense of opiate monitoring and adequate DX of new patients? Or are you saying your NP is as good as you at evals. Either way not good. I see no role for mid levels in our field.

i have no idea how you came to either conclusion, unless you are making significant assumptions that i cannot fathom.

 

[PMR 4 MSK]

Am I misreading or is the point to just make money at the expense of opiate monitoring and adequate DX of new patients? Or are you saying your NP is as good as you at evals. Either way not good. I see no role for mid levels in our field.

100% agree. To use them is to pollute the field.

I see mid levels being used one of 2 ways - the opioid dump, or the "My NP is better than you, the referring doctor."

 

[Ducttape]

100% agree. To use them is to pollute the field.

I see mid levels being used one of 2 ways - the opioid dump, or the "My NP is better than you, the referring doctor."

if you are implying that NPs are making the decisions, then you are wrong. NPs are an extension of my practice.

i see all the new patients at their first appointment - though slows me down to all get out. there are a lot of practices in the area, however, where the doctor does not see the patient at initial eval, and sometimes not until much later. the primary care doctors i have polled about this, however, have no qualms about specialty NPs seeing their patients.


i do not need to see follow up patients who have been on stable doses of medications for years to determine that they are on stable doses of medications every appointment they are scheduled. i also do not need to see the patients who are on WC all the time. i dont need to see the postinjection patients who have been getting the same injections over the years with improvement in functionality and pain and quality of life, whose insurance companies wont pay for further injections without a follow up appointment that says that the shot helped.

i also dont need to spend the 30 min a day on the new evals with data mining, etc. and i dont need to spend an extra 10-15 min screaming at Dragon trying to get that information into the chart.

i do need someone who will help with the initial eval dictations, who will spend the 15-20 min necessary to discuss a multidisciplinary pain management approach that focuses much more on functionality, quality of life measures, and patient safety, who will be able to take call every other week primarily for those pesky hospital calls, who can go in and perform an ODI or get prior auth for MRI or Cymbalta or PT, who is willing to talk to patients about alternative forms of therapy, etc.

what i do is to determine what the probable pain generators are, the therapy to be offered, how it will be offered, and how they will be followed, and the procedures themselves.

 

[specepic]

Settle down boyz

I think someone can use a PA/NP without being considered greedy or lazy

mid levels can be used responsibly and appropriately

just be aware that if you do use them you are training your own future competition own your colleague's future competition

I do not see a role for CRNAs whatsoever in chronic pain, pain procedures

I personally would consider utilizing a PA, but not an NP.

 

[CerebralEdema]

Settle down boyz

I think someone can use a PA/NP without being considered greedy or lazy

mid levels can be used responsibly and appropriately

just be aware that if you do use them you are training your own future competition own your colleague's future competition

I do not see a role for CRNAs whatsoever in chronic pain, pain procedures

I personally would consider utilizing a PA, but not an NP.

Well Said.

 

[PMR 4 MSK]

I could train an MOA to do most of that at 1/10th the salary of an NP, an RN If necessary.

If they are stable on meds, the PCP can write them. To have an NP mainly to write for opioids is going above their level of training. There is not a single NP out there with a fraction of the formal training in opioid use, misuse and abuse that a properly-trained pain physician will have. It's all on-the-job training, which is much harder to defend in court.

I say this as a guy who had an NP for a couple years. I no longer want the vicarious liability.

I also say this as a guy who has been sued in a case ruled as overdose on opioids. On a perfectly stable Pt, on the same dose of meds for over a year.

 

[painstop]

I also say this as a guy who has been sued in a case ruled as overdose on opioids. On a perfectly stable Pt, on the same dose of meds for over a year.

PMR, that is such BS (unless there were obvious red flags your midlevel missed)! So many people refuse to take any personal responsibility for themselves and family members are always looking for someone to blame except the person at true fault to make a quick buck. Was the case dismissed?

 

[PMR 4 MSK]

I also say this as a guy who has been sued in a case ruled as overdose on opioids. On a perfectly stable Pt, on the same dose of meds for over a year.

PMR, that is such BS (unless there were obvious red flags your midlevel missed)! So many people refuse to take any personal responsibility for themselves and family members are always looking for someone to blame except the person at true fault to make a quick buck. Was the case dismissed?

Settled for $95K. Minimal for a death case. Lawyer missed an important deadline. Widow probably got $30K out of it.

It also had funny things like the widow suing for loss of consortium, but she was already remarried when I was served 6 months after he died. He was also in an MVA a few days prior to waknig up dead one morning, and the coroner's report listed subarachnoid hemorrhage in the autopsy. But because he had oxycodone in his system (never found out the blood level - that was lost by the coroner), that was listed as the cause of death, and was the cause of my being sued.

 

[SSdoc33]

Settled for $95K. Minimal for a death case. Lawyer missed an important deadline. Widow probably got $30K out of it.

It also had funny things like the widow suing for loss of consortium, but she was already remarried when I was served 6 months after he died. He was also in an MVA a few days prior to waknig up dead one morning, and the coroner's report listed subarachnoid hemorrhage in the autopsy. But because he had oxycodone in his system (never found out the blood level - that was lost by the coroner), that was listed as the cause of death, and was the cause of my being sued.

and your insurance wanted you to settle b/c it would have been a long, drawn-out thing, lots of hassle, legal fees, etc, right?

and your name goes on some list somewhere that ambulance chasers can access whenever they want.

and you have to fill out paperwork every time you need to recredential, get a new DEA number, state license, etc.

honestly, this makes me want to vomit.

 

[lobelsteve]

and your insurance wanted you to settle b/c it would have been a long, drawn-out thing, lots of hassle, legal fees, etc, right?

and your name goes on some list somewhere that ambulance chasers can access whenever they want.

and you have to fill out paperwork every time you need to recredential, get a new DEA number, state license, etc.

honestly, this makes me want to vomit.

Win, lose, or draw: all of the above happens no matter what.
Settling for under 100k is great. Settling ASAP si excellent at reducing the stress of the nonsense. It is not a reflection on the doctor, it is the business of being a doctor. They are not suing the physician, they are suing his insurance.

SML

 

[painstop]

Is there a statute of limitations on these types of malpractice suits? Obviously there is no statute on murder but this is also not murder. I would think one year is reasonable but I really have no idea.

 

[PMR 4 MSK]

Win, lose, or draw: all of the above happens no matter what.
Settling for under 100k is great. Settling ASAP si excellent at reducing the stress of the nonsense. It is not a reflection on the doctor, it is the business of being a doctor. They are not suing the physician, they are suing his insurance.

SML

Agree 100%. It sucks, but that's the game we play.

 

[PMR 4 MSK]

Is there a statute of limitations on these types of malpractice suits? Obviously there is no statute on murder but this is also not murder. I would think one year is reasonable but I really have no idea.

It varies by state, but often 2 years. Once they file, it can take years to finish. All the while making money for lawyers and stress for doctors. The plaintiffs have nothing to lose, everything to gain. We have nothing to gain.

 

[cbrons]

It varies by state, but often 2 years. Once they file, it can take years to finish. All the while making money for lawyers and stress for doctors. The plaintiffs have nothing to lose, everything to gain. We have nothing to gain.

What state are you in? Is there a state where this is not as much of a problem?

I think its ridiculous that these evil scumbags with law degrees can sue 100% without merit and ruin peoples lives (and their families) in the process.

 

[jsaul]

Are you doing MAC for an RF?

Simple solution is do just do IV sedation with an RN when you think the patient needs it, but skip the CRNA on all your cases.

solution not so simple... at the surgery center I go to -- the anesthesia group there provides anesthesia for all cases. So I either do them with local only or they will do the case. I can not give iv sedation for my own patients-- that would make the anesthesia group through a fit and they will scream at the admin people who will in turn tell me to stop giving sedation and use the anesthesia group who in turn puts one of their 4 crnas in my room

 

[Ducttape]

solution not so simple... at the surgery center I go to -- the anesthesia group there provides anesthesia for all cases. So I either do them with local only or they will do the case. I can not give iv sedation for my own patients-- that would make the anesthesia group through a fit and they will scream at the admin people who will in turn tell me to stop giving sedation and use the anesthesia group who in turn puts one of their 4 crnas in my room

tell them that you will take all of your business away and go somewhere else if a crna is involved and they want to take over all the interventional pain management from you, and you cannot tolerate having someone who might watch you and then start doing them themselves....

 

[bedrock]

solution not so simple... at the surgery center I go to -- the anesthesia group there provides anesthesia for all cases. So I either do them with local only or they will do the case. I can not give iv sedation for my own patients-- that would make the anesthesia group through a fit and they will scream at the admin people who will in turn tell me to stop giving sedation and use the anesthesia group who in turn puts one of their 4 crnas in my room

Are you a part-owner of this ASC? I'd do my cases elsewhere. If you are a part-owner, then talk to the adminstrator who works for you technically and ask for an RN to assist with IV sedation cases.

It must kill your volume to have to wait for anesthesia on those cases. I've done a couple cases with MAC and it added at least 15 minutes to every case. Doesn't really motivate me to use it.

 

[PMR 4 MSK]

What state are you in? Is there a state where this is not as much of a problem?

I think its ridiculous that these evil scumbags with law degrees can sue 100% without merit and ruin peoples lives (and their families) in the process.

I was in TX when I was sued. That particular county was well known for being a lawsuit haven for plaintiffs.

Some states are better for malpractice than others. I moved to Illinois and Texas got better, Illinois worse at malpractice.

 

[cbrons]

I was in TX when I was sued. That particular county was well known for being a lawsuit haven for plaintiffs.

Some states are better for malpractice than others. I moved to Illinois and Texas got better, Illinois worse at malpractice.

WOW! That is amazing. I was just thinking that Texas would be the BEST state to practice in. And I was thinking that Illinois would be the WORST. Wow I was just looking at these two states laws yesterday.

I go to medical school in Illinois.

How is Texas now? How would you say Illinois is now?

 

[PMR 4 MSK]

Illinois is controlled by trial lawyers. Several years ago, we got a cap put on economic damages and the lawyers got it overturned within a year. No attempts at tort reform since then.

Add to that we are essentially bankrupt as a state. Medicaid here is hopelessly underfunded. We're the only state where it is budgeted as a deficit. Over 50% of kids in this state are on Medicaid.

 

[cbrons]

Illinois is controlled by trial lawyers. Several years ago, we got a cap put on economic damages and the lawyers got it overturned within a year. No attempts at tort reform since then.

Add to that we are essentially bankrupt as a state. Medicaid here is hopelessly underfunded. We're the only state where it is budgeted as a deficit. Over 50% of kids in this state are on Medicaid.

Man do I want to leave this state so bad if it doesn't shape up....

 

[PikminOC]

Man do I want to leave this state so bad if it doesn't shape up....

Just go across the border to Wi or Indiana. There is tort reform there correct?

 

[PikminOC]

I could train an MOA to do most of that at 1/10th the salary of an NP, an RN If necessary.

If they are stable on meds, the PCP can write them. To have an NP mainly to write for opioids is going above their level of training. There is not a single NP out there with a fraction of the formal training in opioid use, misuse and abuse that a properly-trained pain physician will have. It's all on-the-job training, which is much harder to defend in court.

I say this as a guy who had an NP for a couple years. I no longer want the vicarious liability.

I also say this as a guy who has been sued in a case ruled as overdose on opioids. On a perfectly stable Pt, on the same dose of meds for over a year.

This is a very important point that is not taught in med school or residency. Alof of hospitals and group practices will try to add collaboration with NP's or supervision of others. Stand your ground! Your license is worth more than a job. The hospital will defend itself.