The Ineffectiveness of our ASA Board

[Noyac]

So the recent tweets by the past AANA President has started a movement of sorts in my community. The general consensus is that our ASA board no longer represents our needs. I personally sent an email to the ASA and received this response:

Please see the response below that is being posted by the ASA Executive Committee regarding Mr. Quintana's defamatory comments. Please don't hesitate to call me with any questions. Theresa

Dear colleagues,

As a number of you have reported, we became aware earlier this week of numerous highly inflammatory, crass and unprofessional "tweets" posted by the immediate past president of the American Association of Nurse Anesthetists. As upsetting and disturbing as these communications are and continue to be, we would urge you not to respond with corrections or indignation, no matter how much they may be deserved. Unfortunately, it is not possible to reason with someone who is not reasonable and the ASA as a professional organization will not be issuing a response. To respond to such communications gives them credence and relevance. These communications are neither accurate, credible nor relevant to our profession, our specialty and the patients whom we serve. We have no reason to believe the "tweets" are being taken seriously by any recipient.

Sincerely,
Jeffrey Plagenhoef, M.D., James Grant, M.D., Linda Mason, M.D. and Daniel Cole, M.D.
ASA Executive Committee

This action, as mentioned by one of my colleagues, is tantamount to persistent inactivity. Is this what we want from our National Society which we pay to act in our best interests?
I am attempting to rally some sort of action. I have found that the state societies may be the best approach. I encourage anyone that feels like there is still something worth fighting for or at least has some pride, write a quick and direct note to your state society requesting they address this issue with the ASA. Apparently, the ASA could care less about the individual members. But the state societies actually carry some weight.

And consider mentioning that for lack of a better term on my part, I would like to quote Trump here, "its time we flush the toilet". Let's get rid of these ASA higher ups and regain the dignity of the profession.

Stop being a pacifist. If you have more than 10yrs left to practice then get off your ass and speak up. It doesn't matter how you say it.. short and sweet, long and redundant, rambling, or even derogatory (probably not the best approach), just speak up.

My state society is discussing it. And yours is probably as well.

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Members don't see this ad.

 

[GigiBuffon]

Completely agree with the OP. The gloves have to come off. The ASA has been ineffective at best dealing with the AANA. For us younger anesthesiologists, this is a matter of our livelihood. Besides calling our state societies... I have another idea: GET INVOLVED IN THE ASA!! It might be time that a few young hardliners get into the ASA and change the pacifist PC attitude in our HQ. We need to start treating the AANA for what it is-- an advertising firm out to spin things any way they can think of to get a larger piece of the pie. Get involved, even if you haven't been much up for political stuff in the past. If enough like-minded people get together, we can turn this ship around. http://www.asahq.org/member-center/appointments-nominations

 

[vector2]

I agree that the ASA has been ineffective, particularly in regard to overall congressional lobbying and an effective and forceful public education message about why physician anesthesiologists are important, but I agree with them 100% about responding to tweets from a clown like Quintana. That just makes us look petty and is a waste of time.

 

[Planktonmd]

The ASA leadership consists of academic guys who have a different view of reality from their ivory tower, many of them are AMCs sympathizers who want to maintain good work relationship with the CRNA union disguised as a professional society named the AANA.

 

[Consigliere]

Yep. And yet you suckers keep throwing money at an organization that opts to take the "moral high ground" while everyone scratches their head wondering why this isn't being addressed. Do you think the ASA's lack of action is being interpreted by the public (and the rest of organized medicine) as not lending "credence and relevance" to this a_ssclown Quintana? If you answered "yes" then please.....keep sending your money to the ASA.

 

[GravelRider]

Here's the problem...much like "draining the swamp" in Washington, "draining the swamp" in the ASA will require removing corporate interests. Again, similar to Washington, that won't happen. The ASA will never represent individual anesthesiologists over the corporate practices that fund them. The corporate practices rely on high supervision ratios to increase profits and thus need to maintain diplomatic relations with CRNA lobby groups like the AANA.

I let my ASA membership expire after residency and have no intention of renewing it. The ASA does not represent me and the fee is way too high.

 

[Outrigger]

If most groups didn't give people CME allowances, ASA membership would drop precipitously.

 

[AdmiralChz]

I'm shocked that more people aren't pushing for or talking about increasing the footprint of AAs. If CRNAs can't play nice in the sandbox maybe we need to think about looking for alternative providers.

 

[Consigliere]

I'm shocked that more people aren't pushing for or talking about increasing the footprint of AAs. If CRNAs can't play nice in the sandbox maybe we need to think about looking for alternative providers.

Good idea but anytime the AAs try to get practice rights in a state, the powerful nursing and AANA lobbies squash it.

 

[Mman]

As much as he's a buffoon, getting in a twitter flame war with an idiot is never a good idea. You just dragged down into the mud and look bad also. We look particularly bad when we start badmouthing CRNAs, because it's politically incorrect to speak poorly of nurses of any kind and they outnumber us (physicians) severely. So you have to pick your battles and do so with savvy.

Everybody with a brain knows that CRNAs are not equivalent to anesthesiologists. It's just that there isn't a really good way to prove it because there is no way to randomize patients and it'd be unethical to do so. Maybe we could get all the nurses in some large metro area to agree to let every sick relative they have undergo all kinds of surgeries with no anesthesiologist present and see how it goes. After a few too many kick the bucket maybe they will relent a little bit.

 

[AdmiralChz]

Good idea but anytime the AAs try to get practice rights in a state, the powerful nursing and AANA lobbies squash it.

Yeah it's unfortunate, especially when they claim a shortage of providers. Our state organizations should really start promoting certifying AAs

 

[jwk]

Yeah it's unfortunate, especially when they claim a shortage of providers. Our state organizations should really start promoting certifying AAs

Thank you for your support and encouragement!

I'm not sure I agree with the "don't respond" perspective. Tweets may not get a wide audience, but other mediums do. In the new issue of Outpatient Surgery there is a "point/counterpoint" with Jay Horowitz CRNA and John Dombroski, MD. Horowitz repeats much of the drivel he had printed in an op-ed piece for The Hill where he claims that he can easily knock $20 billion out of healthcare costs nationwide solely by eliminating medical direction. Of course to fabricate that fantastical and idiotic figure, he assumes that every surgical procedure in the country wastes 22 minutes waiting for an anesthesiologist (as claimed by that equally idiotic ivory tower study) for induction and other medical direction purposes. It's the old "lies, damn lies, and statistics".

 

[pgg]

Yep. And yet you suckers keep throwing money at an organization that opts to take the "moral high ground" while everyone scratches their head wondering why this isn't being addressed. Do you think the ASA's lack of action is being interpreted by the public (and the rest of organized medicine) as not lending "credence and relevance" to this a_ssclown Quintana? If you answered "yes" then please.....keep sending your money to the ASA.

I let my ASA membership lapse. Same reason I quit giving the AMA money years and years ago.


Did MOCA 2.0 eliminate the rule that some CME had to come from the ASA via ACE or SEE? I don't see that requirement listed any more. Just the annual limits, and the 20 unit "patient safety" requirement.

Since the non-member price for that CME is outrageously higher than the member-price ($830 vs $360 for 2017 ACE!), being a member made financial sense to anyone enrolled in MOCA. It looks like that's no longer the case.

 

[deleted126335]

As much as he's a buffoon, getting in a twitter flame war with an idiot is never a good idea. You just dragged down into the mud and look bad also. We look particularly bad when we start badmouthing CRNAs, because it's politically incorrect to speak poorly of nurses of any kind and they outnumber us (physicians) severely. So you have to pick your battles and do so with savvy.

Everybody with a brain knows that CRNAs are not equivalent to anesthesiologists. It's just that there isn't a really good way to prove it because there is no way to randomize patients and it'd be unethical to do so. Maybe we could get all the nurses in some large metro area to agree to let every sick relative they have undergo all kinds of surgeries with no anesthesiologist present and see how it goes. After a few too many kick the bucket maybe they will relent a little bit.

It is my perception that this is exactly why the ASA leadership has not taken a more "aggressive" public media campaign. Nasty, insulting newspaper ads disparaging CRNAs might make us feel good transiently, but they are less likely to be effective than quiet lobbying and thoughtful articulate letters to decision makers. I don't know that this philosophy is right, I also don't know that it is wrong. I am willing to give the benefit of the doubt and my PAC $ to the leadership.

 

[pgg]

It is my perception that this is exactly why the ASA leadership has not taken a more "aggressive" public media campaign. Nasty, insulting newspaper ads disparaging CRNAs might make us feel good transiently, but they are less likely to be effective than quiet lobbying and thoughtful articulate letters to decision makers. I don't know that this philosophy is right, I also don't know that it is wrong. I am willing to give the benefit of the doubt and my PAC $ to the leadership.

I was a loyal dues-paying ASA member until last year, and a chairman's council level donor to ASAPAC for a few years. I thought that $1500 a year (or whatever it was) was a worthwhile expenditure, even though there was never any hope that they could impact independent CRNA practice in the military, where I worked and got paid sub-market wages. I figured that in the decade or so between my residency graduation and my exit from the military, they could meaningfully alter the trajectory of the specialty.

They haven't.

Deliberating about whether their approach is right or wrong is a sidebar to the real issue: they're failing.

It's actually worse than that. Their major effort has been to change the specialty itself into some kind of perioperative clinic-drone surgeon-scut-monkey "we'll do a bunch of pre and post op optimizing work that could be better done by other physicians (or even midlevels) in the sad hope that it'll make us look more valuable" ... while meekly ceding the operating room and the actual delivery of anesthesia to nurses.

The ASA didn't have to be nasty or insulting to defend the specialty, they just had to insist that we be involved with every anesthetic. There are positive and uplifting ways to do this. Radiologists do it with big posters in hospitals detailing the extent of their training and how important it is that studies get read by radiologists. They don't insult the doctors who order the studies and look at the images themselves.

I'm not poor, but I'm not rich. I've got better things to do with my $1500/year than give it to an organization that can't be bothered to fight for the specialty I want to be part of.

I've come 180 degrees on this. Just a few years ago, on this very forum, I was nagging people to join the ASA and give money to ASAPAC. A search will turn up the posts.

I think Noyac is probably right - maybe state societies and state PACs are where I should be giving money.

 

[Mman]

It's actually worse than that. Their major effort has been to change the specialty itself into some kind of perioperative clinic-drone surgeon-scut-monkey "we'll do a bunch of pre and post op optimizing work that could be better done by other physicians (or even midlevels) in the sad hope that it'll make us look more valuable" ... while meekly ceding the operating room and the actual delivery of anesthesia to nurses.

that didn't originate with the ASA, it originated with the people that pay the bills (CMS and insurance companies). ASA is trying to get out front of it because you either do it yourself on your own terms or have them dictated to you by someone else. And nobody is "ceding" the OR to nurses, it's just a difficult thing to stand up and scream about when you will draw stares from millions of nurses sticking up for some other nurse. We are outnumbered by a lot.

 

[GravelRider]

The fact that we are even having discussions about how anesthesiologists are not viewed as physicians by patients or nurses shows a failing of the ASA. What is so wrong about having an aggressive public relations campaign? There is no need to insult CRNAs, but educating the public in a meaningful way on the importance of having a good anesthesiologist in charge of your surgery would go a long way in creating confidence that the ASA actually cares about the long term prospects of the specialty.

I think state societies are a start and like most things political, your voice is louder on a local level rather than on a national level. However, there is still a need for national level organizations to represent the specialty as a whole in order to deliver a unified message. Healthcare is a constant source of political discussion in Washington D.C., so we still need an organization that will represent individual anesthesiologists at a national level. The ASA only seems interested in selling me the latest video laryngoscope, convincing me to work for Sheridan, or trying to sell me overpriced study materials for the ridiculous MOCA requirements.

In terms of the Surgical Home thing, I don't think that was created in response to CRNA encroachment, but rather in response to changes in how we will be paid. I don't want to be a post-op surgical PA getting calls about blood sugars or constipation, but I think there are some aspects of the surgical home that would be wise for departments to adopt. I think the current message put forth regarding the surgical home is a failing of the ASA. Instead of promoting the surgical home as some sort of pre-op clinic or post-op medical management, there should be an effort to encourage more departments to get involved with things like acute care anesthesiology, critical care, and acute pain services. These are things that are in our "wheelhouse" and accomplish the goals of expanding our reach outside of the OR in a meaningful way. It isn't about ceding the OR, but rather improving the flow through the OR both in patient outcomes and efficiency. Again, this is communicated very poorly by the ASA. Whenever I try to figure out what the ASA is actually saying regarding the surgical home, I see a variety of Venn diagrams and flow charts that only serve to confuse me even more.

 

[Arch Guillotti]

Good idea but anytime the AAs try to get practice rights in a state, the powerful nursing and AANA lobbies squash it.

Let alone getting them in a place with CRNA's; although it's possible.

 

[Consigliere]

I think there are some aspects of the surgical home that would be wise for departments to adopt. I think the current message put forth regarding the surgical home is a failing of the ASA. Instead of promoting the surgical home as some sort of pre-op clinic or post-op medical management, there should be an effort to encourage more departments to get involved with things like acute care anesthesiology, critical care, and acute pain services. These are things that are in our "wheelhouse" and accomplish the goals of expanding our reach outside of the OR in a meaningful way. It isn't about ceding the OR, but rather improving the flow through the OR both in patient outcomes and efficiency. Again, this is communicated very poorly by the ASA. Whenever I try to figure out what the ASA is actually saying regarding the surgical home, I see a variety of Venn diagrams and flow charts that only serve to confuse me even more.

Sounds like someone has been drinking the surgical home Kool-Aid....

 

[dhb]

As much as he's a buffoon, getting in a twitter flame war with an idiot is never a good idea. You just dragged down into the mud and look bad also.

There wasn't a need to get into a twitter war with him but it was a nice opportunity to get out and do some PR work

 

[GravelRider]

Sounds like someone has been drinking the surgical home Kool-Aid....

Because doing preops, signing charts, and watching Fox News in the lounge is working out so well for us. The specialty is as healthy as ever, right? Instead we whine about how patients don't know we are physicians and talk about engaging in twitter wars with nurses over who is the real doctor. The ASA is an impotent organization, but there is also an inertia within the specialty to evolve in a way that would make discussions about the worth of our specialty indisputable.

 

[pgg]

that didn't originate with the ASA, it originated with the people that pay the bills (CMS and insurance companies). ASA is trying to get out front of it because you either do it yourself on your own terms or have them dictated to you by someone else.

There are two separate issues here

1) Getting "out in front" of changing payment schemes, and getting our piece of bundled payments. The ASA seems to think the best way to do this is to make ourselves useful out of the OR. Time will tell if they're right about that.

2) Stopping independent CRNA practice. The ASA clearly isn't interested in that. They seem happy to let it happen, presumably while we're keeping busy and making ourselves useful out of the OR.

And nobody is "ceding" the OR to nurses,

The ASA had an economist give the keynote speech at its annual meeting a few months ago. The guy said

In this field, we have a religious debate about nurse anesthetists. You've got to stop that debate. We're dinosaurs if we keep having that debate.

When your keynote speaker at your national meeting tells the rank and file to STFU about it, the issue has been ceded.

it's just a difficult thing to stand up and scream about when you will draw stares from millions of nurses sticking up for some other nurse. We are outnumbered by a lot.

It is difficult. I don't disagree with that.

 

[ERRES2288]

Is it possible the specialty isn't in as much trouble as some think? Sure supervision is here to stay but I highly doubt there are going to be independent CRNA providers in even remotely large hospitals anytime soon.

 

[deleted126335]

Is it possible the specialty isn't in as much trouble as some think? Sure supervision is here to stay but I highly doubt there are going to be independent CRNA providers in even remotely large hospitals anytime soon.

The model will most likely be, "How few anesthesiologists can we get away with to staff a gaggle of CRNAs?"

 

[ERRES2288]

The model will most likely be, "How few anesthesiologists can we get away with to staff a gaggle of CRNAs?"

What's the highest ratio you've heard of? I was under the impression it's mostly 3 or 4-1 and has been this way for decades in supervision practices. What makes you think it's all the sudden going to change?

 

[Arch Guillotti]

What's the highest ratio you've heard of? I was under the impression it's mostly 3 or 4-1 and has been this way for decades in supervision practices. What makes you think it's all the sudden going to change?

6-8:1.

 

[Scotty_G]

You guys are going to laugh I interviewed with a private group in Florida where they had an AA training program but also had crna's on staff! During my interview I shadowed the Dr supervising and we went into an ortho room. It was the A.A.'s student first day and the Attn let the AA do the spinal. Meanwhile after that we left and the AA student stayed in the room with the CRNA. When I saw that I lost respect for the group.

 

[anesthesiadoc]

The way I see it, no major conflict or competition was ever won on defense. Every ASA intervention or campaign I've been made aware of involved the ASA fighting to repeal an initiative or bill somewhere that the AANA had put forth to gain more independence. So we rally, get a few thousand signatures and a bunch of donations, to not let the sand wash away from our beach. It sounds stupid even writing about it. I'd support the ASA and resume my donations to the PAC if, instead, I received updates about the new laws that our team put forth increasing supervision requirements, capping ratios at 1:3. Let the AANA spend their time undoing legislation that we put forth. That would get my attention and my support. Otherwise we're just rearranging deck chairs on the failboat...


Sent from my iPhone using SDN mobile

 

[WholeLottaGame7]

I was always taught that calm, intelligent, rational, reasoned discourse would win out over loud, obnoxious, uninformed, incoherent drivel. Or, to put it another way, as others have said, never get into a fight with an idiot, because they will drag you down to their level and beat you at their own game.

It never really seemed true in grade school or middle school or even high school, really, but I held out hope that eventually it would work that way. And maybe it started to feel a little like that in college and medical school.

But given recent world events, I'm starting to think my worldview might be wrong. Because it sure seems like the people who are the loudest and most confident are winning, regardless of how informed or coherent they are. Maybe because the population at large is uninformed and incoherent so they don't care? I guess there's a reason we write consent forms at a first grade level...

 

[zero0]

I was always taught that calm, intelligent, rational, reasoned discourse would win out over loud, obnoxious, uninformed, incoherent drivel. Or, to put it another way, as others have said, never get into a fight with an idiot, because they will drag you down to their level and beat you at their own game.

It never really seemed true in grade school or middle school or even high school, really, but I held out hope that eventually it would work that way. And maybe it started to feel a little like that in college and medical school.

But given recent world events, I'm starting to think my worldview might be wrong. Because it sure seems like the people who are the loudest and most confident are winning, regardless of how informed or coherent they are. Maybe because the population at large is uninformed and incoherent so they don't care? I guess there's a reason we write consent forms at a first grade level...

In a world of sane rational people, maybe, but we don’t live in that kind of world. Here, if you repeat something loudly and often enough, people just start believing it, and the nurses are the ones with the loudest voice. Part of the reason is because they’re actually united.

Despite how it seems on SDN, anesthesiologists are actually divided on the CRNA issue. I couldn’t believe it. You can imagine the look of shock and horror that came over my face when I came across my first anesthesiologist who preferred supervising CRNAs. I couldn’t rationalize it, not after everything I read, but I didn’t have time to ask questions. I was too frightened by the dangerously insane human being standing before me and ran for my life.

I got the message eventually. Yup, money. Guess he was one of those old guys I’ve been hearing about who doesn’t care about the future of the profession and is getting ready to cash out.

The AANA campaign also gets a lot more publicity partly because it piggybacks on the much larger thriving midlevel propaganda currently sweeping the country. The number of landmark legislation passed in their favor in the last few years alone is alarming. Words like “provider” are shoved down our throats while “midlevel” has become a derogatory term. No joke, the last hospital I was at forbid doctors from using that word. Something about it giving the nurses and PAs boo boos on their feelings.

 

[Mman]

Despite how it seems on SDN, anesthesiologists are actually divided on the CRNA issue. I couldn’t believe it. You can imagine the look of shock and horror that came over my face when I came across my first anesthesiologist who preferred supervising CRNAs. I couldn’t rationalize it, not after everything I read, but I didn’t have time to ask questions. I was too frightened by the dangerously insane human being standing before me and ran for my life.

No offense, but as a med student I'm not sure you are qualified to weigh in on that topic. I mean do you complain about ICU physicians that cover 16-24 patients at a time? If not, what's wrong with an anesthesiologist covering 3-4 ORs at a time when they include ASA 1 patients and maybe 1 big case? I personally feel that ACT model is the best for me and it's not about money. I'd work for less money. Why? Because I get to do more. I manage more airways, I put in more lines, I put in more blocks. Sitting in a room during a long boring case is not what I trained for a long time to do.

 

[BLADEMDA]

The ASA and our PAC are far from ideal. But, to withdraw our financial support is pure career suicide. Thus, I continue to be a member of the ASA and donate to my PACs.
For those that have decided to just give up on the fight I only ask that you reconsider this tactic; the AANA is a powerful adversary and we must continue the struggle against them.

Keeping the AANA from obtaining independent practice at our VA hospitals was a major victory. This required money and a lot of effort. While we may ultimately lose the war against the AANA I truly believe that people like PGG can finish their careers without ever seeing Independent CRNA practice at our major hospitals in the USA. If we withdraw our support the AANA will simply cruise to victory in just a few years.

For those that truly believe CRNAs shouldn't be practicing independently in the USA the ASA and our PACs remain the best defense against the AANA.

http://www.aana.com/advocacy/federa...GER VHA Frequently Asked Questions- FINAL.pdf

 

[BLADEMDA]

 

[BLADEMDA]

 

[GravelRider]

No offense, but as a med student I'm not sure you are qualified to weigh in on that topic. I mean do you complain about ICU physicians that cover 16-24 patients at a time? If not, what's wrong with an anesthesiologist covering 3-4 ORs at a time when they include ASA 1 patients and maybe 1 big case? I personally feel that ACT model is the best for me and it's not about money. I'd work for less money. Why? Because I get to do more. I manage more airways, I put in more lines, I put in more blocks. Sitting in a room during a long boring case is not what I trained for a long time to do.

Wrong. He/She is perfectly qualified to question the tactics of how things are done. Maybe supervising 3-4 rooms has not been good for the profession. Maybe an ICU doc covering 24 patients is not good for patient outcomes. If not for a newer generation or newer voice questioning old ways then we would never have advancements. It's this stubborn feeling by the old timers that they deserve more simply because they were there first that is sinking the profession. It's exactly why the ASA is an impotent and useless organization. It is cronyism at its worst for corporate medicine. We need new minds and a fresh set of eyes on this problem.

 

[Noyac]

Thanks for the videos Blade.
Why is it that this is the first time I see these. They should have been out there all this time.
I guess they were, just not in my area.

 

[BLADEMDA]

 

[Consigliere]

No offense, but as a med student I'm not sure you are qualified to weigh in on that topic. I mean do you complain about ICU physicians that cover 16-24 patients at a time? If not, what's wrong with an anesthesiologist covering 3-4 ORs at a time when they include ASA 1 patients and maybe 1 big case? I personally feel that ACT model is the best for me and it's not about money. I'd work for less money. Why? Because I get to do more. I manage more airways, I put in more lines, I put in more blocks. Sitting in a room during a long boring case is not what I trained for a long time to do.

I am and he/she is NOT qualified. Some starry eyed, idealistic med student's opinion goes right where I throw my ASA dues statement - directly in the garbage.

I just can't understand the holier-than-thou "I do my own cases" crowd that look down their noses on ACT model anesthesiologists. These group of anesthesiologists deem themselves so high and mighty simply because they sit on a stool, watching an intubated, paralyzed pt. while charting vitals q 5 minutes. They mock ACT anesthesiologists and refer to them in pejorative terms such as "lazy ass freeloaders." I guarantee you I work harder than ANY anesthesiologist who does their own cases. I'm the one putting in all the central lines, doing all the peripheral nerve blocks, seeing every pt. that is going to the OR and devising an anesthetic plan for them, bailing out CRNAs countless times, doing the difficult spinals and intubations, and numerous other activites I've lost the desire to list. A *****....a certifiable IQ-of-65 having ***** can do easy spinals and intubations. In most parts of the USA, the ACT model is the prevalent model and the choice is: ACT practice or unemployment.

 

[BLADEMDA]

I'd rather do my own case than run around all day covering 4-5 rooms and dealing with the CRNAs. I've been at this gig for over 2 decades and I can tell you doing your own room is far easier than covering 4 or even 3 rooms in an acute care hospital.

Since I've had the opportunity to do both during my career (own cases and covering 4-5 rooms) I feel qualified to bluntly say that a busy ACT practice will wear you down far faster than if you do your own cases solo. But, if you only cover CRNAs or AAs 2:1 or less then the dynamic shifts to supervising being the easier practice.

 

[BLADEMDA]

 

[BLADEMDA]

The Problems of Certified Registered Nurse Anesthetists


More than any other specialty, anesthesiology in the United States has blurred the distinction between physicians and nurse-practitioners. This confusion of roles has its roots in the late differentiation of anesthesiology as a specialty. There was a considerable period during which anesthesia delivery consisted of a paper cone and a container of ether, both held by a nurse. This created a perception that anesthesia was a nursing task. With the certification of registered nurse anesthetists (CRNAs), surgeons explicitly accepted that anesthesia could be practiced by a nurse, albeit under the supervision of a surgeon. This pattern of allowing nurses to practice a medical specialty did not pose a problem until anesthesia practice began to become much more sophisticated and technologically oriented.


Board certification in anesthesia now requires a medical degree, training in a formal residency, and passing a certification examination. This creates an enormous gulf between the knowledge base of CRNAs and physician anesthesiologists. It also creates a knowledge gap between board-certified anesthesiologists and physicians who practice anesthesia without formal training. Such physicians include family practitioners who provide anesthesia in rural hospitals, noncertified physicians who hold themselves out as anesthesiologists, and most surgeons who supervise CRNAs.


A major controversy between surgeons and anesthesiologists is the proper role of CRNAs. Few, if any, states allow the independent practice of anesthesia by nurses. The legal expectation is that the CRNA will be supervised by a properly qualified anesthesiologist. If the CRNA is not under the supervision of an anesthesiologist or if this supervision is too attenuated, the law will assign the surgeon legal responsibility for the CRNAs' actions. (See Chapter 15.)


Medical malpractice insurance rates for CRNAs are artificially low because the nurses do not bear primary responsibility for any negligent actions. When a CRNA injures a patient, the legal liability for that injury flows directly to the supervising physician--either the surgeon or the anesthesiologist. In some cases, the nurse is not even sued. In cases where the CRNA is not supervised by an anesthesiologist, the plaintiff's attorney focuses on the surgeon rather than the CRNA. The surgeon is a much less sympathetic target in front of a jury. As the licensed physician in charge, the surgeon is expected to know all aspects of anesthesiology practice. Plaintiffs' attorneys are able to make supervising surgeons appear negligent by forcing them to admit that they relied on the nurse's knowledge of anesthesia. This is ethically questionable and violates the medical practice act in most states because it is impossible to supervise care that one does not understand.

http://biotech.law.lsu.edu/Books/lbb/x943.htm

 

[Mman]

Wrong. He/She is perfectly qualified to question the tactics of how things are done. Maybe supervising 3-4 rooms has not been good for the profession. Maybe an ICU doc covering 24 patients is not good for patient outcomes. If not for a newer generation or newer voice questioning old ways then we would never have advancements. It's this stubborn feeling by the old timers that they deserve more simply because they were there first that is sinking the profession. It's exactly why the ASA is an impotent and useless organization. It is cronyism at its worst for corporate medicine. We need new minds and a fresh set of eyes on this problem.

Somebody with no experience even being a resident isn't qualified to comment on the mechanics of doing your own case vs supervising. I mean they've never even done a case. At least a senior resident has done some cases on their own and maybe had some experience supervising junior residents. A med student? Really? Do you also ask them for their preferred technique for starting an arterial line?

I get you don't like the ASA. That's fine. People should question everything. But a med student isn't capable of providing reasoned arguments one way or the other on this topic. And I'm definitely not an old timer as I've got colleagues 30+ years older than me still going strong.

 

[Mman]

These group of anesthesiologists deem themselves so high and mighty simply because they sit on a stool, watching an intubated, paralyzed pt. while charting vitals q 5 minutes.

If you have an electronic record system and an IV pump, it's quite possible to do some cases where you do not have to do anything (chart anything, push any meds, etc) for an hour at a time. Get up every hour, dump the foley, maybe spike a new bag of fluid, and relax. Is every case like that? Of course not. But if you do it right, some are.

 

[Noyac]

OK I may have started this banter and I apologize. Lazy ass freeloaders was uncalled for.

Please, can we discuss constructively and educate the students and residents without attacking everyone.

Btw, I have worked in both the ACT and the physician only model. I much prefer the physician only model.
Both can be easy and both can be difficult.

 

[Noyac]

Another decent video but I was disappointed that he couldn't remember, much less state the study showing anesthesiologist>nurses. He should have been prepared better.

 

[GravelRider]

Somebody with no experience even being a resident isn't qualified to comment on the mechanics of doing your own case vs supervising. I mean they've never even done a case. At least a senior resident has done some cases on their own and maybe had some experience supervising junior residents. A med student? Really? Do you also ask them for their preferred technique for starting an arterial line?

I get you don't like the ASA. That's fine. People should question everything. But a med student isn't capable of providing reasoned arguments one way or the other on this topic. And I'm definitely not an old timer as I've got colleagues 30+ years older than me still going strong.

I'm sorry, I just don't buy that. We work in a system where people with no medical experience whatsoever question us. There is constant discussion about showing value to some administrator with an MBA. It's ok for the MBA to give suggestions or question systems, but not ok for the medical student? I think it is perfectly reasonable to question why an attending anesthesiologist would prefer working with a CRNA over a resident. Do you know why they prefer the CRNA? I do. We all do. There is an inherent duty and prestige that is being lost in the entire medical profession because of this mindset. It is the reason why the public image of physicians is deteriorating and it is perfectly reasonable for a medical student to question this. In fact, they are probably the most qualified to question this. Your example of whether I would ask a med student for advice on an arterial line is not equivalent. The medical student is questioning the system they are investing in, not an actual medical technique.

 

[Mman]

I'm sorry, I just don't buy that. We work in a system where people with no medical experience whatsoever question us. There is constant discussion about showing value to some administrator with an MBA. It's ok for the MBA to give suggestions or question systems, but not ok for the medical student? I think it is perfectly reasonable to question why an attending anesthesiologist would prefer working with a CRNA over a resident. Do you know why they prefer the CRNA? I do. We all do. There is an inherent duty and prestige that is being lost in the entire medical profession because of this mindset. It is the reason why the public image of physicians is deteriorating and it is perfectly reasonable for a medical student to question this. In fact, they are probably the most qualified to question this. Your example of whether I would ask a med student for advice on an arterial line is not equivalent. The medical student is questioning the system they are investing in, not an actual medical technique.

the poster I replied to did not mention an attending preferring to work with a CRNA instead of a resident. They were preferring supervising a CRNA instead of doing MD only care. The word resident wasn't in there anywhere and I don't know how else you'd read it.

So yes, medical students can ask questions. They should. But they also don't have a basis to express shock and disgust that an anesthesiologist might prefer the ACT model to MD only care since they have no relevant experience with either.

I think you probably misread the post I replied to. As to your other point, yes administrators/MBAs can ask questions. Just like students. But if they don't know what they are talking about, they get the same quick correction.

As a profession and specialty, we are basically obligated to fight for the ACT model in this country regardless of your personal preference for that vs MD only care by the sheer math of number of anesthesiologists vs number of surgical procedures done in this country each year. I fully support the idea of groups providing MD only care. I personally don't want to do it as it bores me, but I think it's great that the option is there. We do, however, absolutely positively need the preservation of medical direction of CRNAs by anesthesiologists. There are a lot of bad CRNAs that will kill people if left to their own devices. There are also some good ones that would likely be just fine. But they are fine in the current model, too, whereas the bad ones are protected from hurting people.

 

[likeaboss]

The Problems of Certified Registered Nurse Anesthetists


Few, if any, states allow the independent practice of anesthesia by nurses. The legal expectation is that the CRNA will be supervised by a properly qualified anesthesiologist. If the CRNA is not under the supervision of an anesthesiologist or if this supervision is too attenuated, the law will assign the surgeon legal responsibility for the CRNAs' actions. (See Chapter 15.)


http://biotech.law.lsu.edu/Books/lbb/x943.htm

copyright 1993...

 

[Noyac]

I fully support the idea of groups providing MD only care. I personally don't want to do it as it bores me,.

I prefer boredom to fixing stupid mistakes created by others.

When I supervised, I found the days that I was supervising the good nurses to be the most boring thing ever. And the days that I supervised the weaker ones to be extremely frustrating.

 

[Mman]

I prefer boredom to fixing stupid mistakes created by others.

When I supervised, I found the days that I was supervising the good nurses to be the most boring thing ever. And the days that I supervised the weaker ones to be extremely frustrating.

that's why I like the idea of having both models available, but as a specialty if we advocate to get rid of ACT model we are by definition advancing the cause of independent CRNAs.