To Gas or Not to Gas: That is the question

[Skip Intro]

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[Fermata]

Gas is a pretty cool specialty.

It carries a great responsibility that you should be comfortable with.

 

[2ndyear]

Good: Fast, exciting, acute medicine. You get to use amazing pharmacologic agents and do real procedures. Just think for a minute where most doctors comfort level is with critical patients. Not very high. Think who in their right mind would want to first administer an agent that will paralyze the person and make them stop breathing, then care for them when they are being cut open from head to toe. That's what's cool about gas. You are the end point, when someone's BP drops in the OR you don't call someone for a consult or wait and remeasure. You react, same thing goes for difficult airways. After doing other rotations now everything else just seems boring.

Bad: Lots of people love chronic disease and managing it. Well at least they must because a whole lot of people match IM every year. You don't do this in anesthesia. Relationships are short. It's 24 hours, but what isn't. Mid-levels can provide some of the care you do, but this isn't unique to anesthesia either.

 

[MacGyver]

Originally posted by 2ndyear
Mid-levels can provide some of the care you do, but this isn't unique to anesthesia either.

Yeah, but the trend is FAR more mature in gas than in other fields.

Also, I challenge you to name one scenario in which a CRNA is unqualified to run the gas without an MD present.

 

[MacGyver]

Originally posted by Skip Intro
True, but you're open to doing a Pain fellowship.

CRNAs have their own subspecialty pain fellowships too.

 

[UTSouthwestern]

Back again MacGuyver?

Did you find the answers you were looking for on the surgery board and are you still trying to criticize anesthesiologists?

Anesthesiologists may have more mid level competition than other fields right now, but don't think that you will be immune to that factor. The nurse practitioner school in the DFW area is already cranking out graduates for both surgical and primary care fields. This year, they will expand the number of "residency" slots and are looking to increase their presence in the medical subspecialties. Will they be content to be "directed" by doctors or will they also continue to push for independent practitioner status as they are already pushing for in rural areas?

Fortunately, the results of the match show that your beliefs do not reflect the majority of the talented medical students that poured into anesthesiology this year. Only the worst and most arrogant programs failed to fill or attract superior resident candidates. These and future candidates do not shy away from a challenge as you would have them do.

Hopefully, you are as satisfied or will be as satisfied with your career choice as we are with ours because your constant rants seem to reflect on a deeper level your own disatisfaction either with your current or future prospects.

We will work hard and we will be compensated well for our hard work and diligence. At some point, you may come to understand why we are so well compensated and relied upon as a safety net for all critical scenarios. I just hope that in your zeal to suppress enthusiasm for my profession that you don't experience a crisis for lack of our presence and support.

 

[NaeBlis]

Originally posted by UTSouthwestern
Back again MacGuyver?

Did you find the answers you were looking for on the surgery board and are you still trying to criticize anesthesiologists?

Anesthesiologists may have more mid level competition than other fields right now, but don't think that you will be immune to that factor. The nurse practitioner school in the DFW area is already cranking out graduates for both surgical and primary care fields. This year, they will expand the number of "residency" slots and are looking to increase their presence in the medical subspecialties. Will they be content to be "directed" by doctors or will they also continue to push for independent practitioner status as they are already pushing for in rural areas?

Fortunately, the results of the match show that your beliefs do not reflect the majority of the talented medical students that poured into anesthesiology this year. Only the worst and most arrogant programs failed to fill or attract superior resident candidates. These and future candidates do not shy away from a challenge as you would have them do.

Hopefully, you are as satisfied or will be as satisfied with your career choice as we are with ours because your constant rants seem to reflect on a deeper level your own disatisfaction either with your current or future prospects.

We will work hard and we will be compensated well for our hard work and diligence. At some point, you may come to understand why we are so well compensated and relied upon as a safety net for all critical scenarios. I just hope that in your zeal to suppress enthusiasm for my profession that you don't experience a crisis for lack of our presence and support.

You know he never did get back to us on that dozen or so studies he claimed existed. I wonder why?

 

[UTSouthwestern]

Perhaps because he finally realizes that his depictions of our field are not so different from his.

Welcome to your worst nightmare MacGuyver:

"In addition to diagnosing and managing acute episodic and chronic illnesses, nurse practitioners emphasize health promotion and disease prevention . . .Nurse practitioners practice AUTONOMOUSLY and in COLLABORATION WITH healthcare professionals and other individuals to diagnose, TREAT AND MANAGE THE PATIENT'S HEALTH PROBLEMS. They serve as HEALTH CARE RESEARCHERS, interdisciplinary CONSULTANTS and patient advocates."

Oh my.

Welcome to the face of YOUR competition: the AANP.

 

[MacGyver]

I will worry about surgery when I see NPs running their own surgeries with no MD oversight (i.e. current CRNA practice in anes).

There is not a single surgery that is done in this country in which an NP did it without an MD present who did the major part of the surgery. The best they can hope for is first assist status.

Unlike gas, surgeons actually protect their turf. Sure, there may be disagreements within the surgery field as far as gen surg vs surg subspecialties, but as far as midlevels, surgeons are just about the only group of doctors which have actively fought against midlevels and didnt sell out their profession for temporary $$$$.

 

[UTSouthwestern]

You mean as far as you can tell or at least in the big cities. In any event, you could argue that surgeons have already "sold out" their profession by giving NP's clinical autonomy, coordinator's positions, and surgical priveleges, monitored or not. Why did they do that? No not to make "temporary $$$$": No they wanted long term $$$$ on the cheap rather than hiring physicians for those duties in their practices as some groups have hired internists or FP's to do. Still on the high horse? . . .


When will NP's operate independently? . . .




Welcome to the AANP.

 

[Skip Intro]

Well, since you've hijacked my thread, MacGyver, I think you should read this...

http://www.aana.com/crna/prof/legal.asp

I get the sense that nurse anesthetists are quite tetchy about the fact that the laws in every state still require that they be supervisd by a physician.

-Skip

 

[Drakensoul]

Originally posted by Skip Intro
Well, since you've hijacked my thread, MacGyver, I think you should read this...

http://www.aana.com/crna/prof/legal.asp

I get the sense that nurse anesthetists are quite tetchy about the fact that the laws in every state still require that they be supervisd by a physician.

-Skip

"...The laws of every state permit CRNAs to work directly with a physician or other authorized health care professional without being supervised by an anesthesiologist."

It says that they don't need to be supervised to provide anesthesia, Skip. Or rather, they only have to be supervised in some states. Some see this (the ability of CRNAs to do basically everything MDAs can) as a huge threat to anesthesiologists..

I, myself, am very interested in the field. I figure that if people are still complaining about the threat of CRNAs when I'm an MS4 (read: it still hasn't become an actual problem), I'll say "screw it," and go into it anyway.

Here's hoping!

 

[sleep deprived]

Speaking of "GAS," I had this weird experience at the dentist's office. He gave me nitrous oxide and it completely uninhibited me and I started like flirting with him and coming on to him. I was aware I was doing it, and I wanted to stop, but I couldn't!!! I was so humiliated!! I told him he had a nice a$$!
Anyone ever heard of this happening with Nitrous oxide? Is it unusual?

 

[Drakensoul]

Originally posted by sleep deprived
Speaking of "GAS," I had this weird experience at the dentist's office. He gave me nitrous oxide and it completely uninhibited me and I started like flirting with him and coming on to him. I was aware I was doing it, and I wanted to stop, but I couldn't!!! I was so humiliated!! I told him he had a nice a$$!
Anyone ever heard of this happening with Nitrous oxide? Is it unusual?

I'm sure you made his day

 

[sleep deprived]

He was laughing really hard and getting a kick out of it. I was humiliated.
When he took the nitrous off of me I felt like I was going to faint, I was so dizzy and light headed it wasn't funny.

 

[MacGyver]

Skip,

A few states require MDA supervision over CRNAs.

A few more require a CRNA and an MDA to "collaborate." Even the word "collaborate" does not mean supervision. Hell, in those states, the "collaborating" MDA never even has to meet the CRNA in person!

The rest of the states allow CRNAs to run gas without any kind of relationship AT ALL to an MDA.

Its not uncommon to find gas practices that are 100% staffed by CRNAs that have exclusive contracts with hospitals.

 

[juddson]

Skip,

You are reading this article the wrong way around. According to the article, EVERY STATE permits a CRNA to work with a physician or surgeon WITHOUT the supervision of an MDA. That is, every state permits a surgeon and an CRNA to be the only providers in the surgery room.

And why is it that only Gas requires a "team" of providers? Explain that to me. The AANA is doing a much better job gaining turf than the ASA is in keeping it. I'm not sure why the ASA appears to be asleep at the switch.

BTW, is MacGyver a surgeon (or whatever)? I was under the impression that he was a premed. Maybe I have this wrong. MacGyver, care to enlighten. In any event, I interviewed at one of my med schools with an MDA. She told me as clear as day that the reason she has come into accademia is due to being driven out of practice by CRNA's in her old state. That was enough for me.

Judd

 

[NaeBlis]

Originally posted by MacGyver
Skip,


Its not uncommon to find gas practices that are 100% staffed by CRNAs that have exclusive contracts with hospitals.

Its actually extraordinarily rare to find a practice with no MDA's. But since when have facts bothered you Mac.

 

[UTSouthwestern]

It's not uncommon to find private practitioners gravitating back to academics late in their career, but the exodus over the past 10 years has been heavily weighted toward private practice. We've had to replace many faculty members over the past 5 years who have taken lucrative private practice jobs in even a saturated market like Dallas. At the same time, we have seen a number of older anesthesiologists semi-retire to academics.

 

[MacGyver]

Skip Intro,

give it up. Its well established that CRNAs in many states (not all) can indeed form their own practices and work 100% independently of an MDA.

Here's proof from Texas:

http://www.txana.org/AboutTANA/TXCRNAPractice.asp

Remember that CRNAs do work as independent providers and are independently licensed and legally responsible and accountable for their own practices in Texas. They may practice as private practitioners on the basis of their own clinical privileges within hospitals or surgicenters; they may independently contract for the provision of anesthesia services in facilities; or they may be employed by a hospital, surgicenter, a group of MDs, or a surgeon.

In the state of Texas, physician supervision is not required to practice. The Board of Nurse Examiners for the State of Texas, which regulates CRNAs, say that the practice if anesthesia by CRNAs is the practice of nursing and that CRNAs function independently and do not require supervision from a physician.

Here's more proof from California:

CRNAs can provide anesthesia services in all settings in California without the supervision or direction of a physician anesthesiologist or surgeon. According to the Board of Registered Nursing, "the CRNA as a licensed independent practitioner, is responsible for selecting and administering the anesthetic agent, monitoring the patient's response, and selecting and administering drugs required to maintain the patient's stability during the perioperative period."

BTW, CRNAs do NOT get paid as much as MDAs:

http://www.nurseweek.com/features/00-02/anest.html

The median income for anesthesiologists is $244,000 a year, according to the ASA, compared to $88,000 for CRNAs.

More evidence of your ignorance regarding CRNA indepent practice:

http://www.nursesource.org/anesthetist.html

CRNAs are the sole anesthesia providers in approximately 50% of all hospitals

 

[UTSouthwestern]

Welcome to the AANP. . .

 

[Skip Intro]

Originally posted by MacGyver
Here's proof from Texas...

And, here's proof that they cannot practice independently, per Texas' own statutes (unless you naively consider following a physician co-authored protocol as "independent practice")...

?221.13. Core Standards for Advanced Practice.

(a) The advanced practice nurse shall know and conform to the Texas Nursing Practice Act; current board rules, regulations, and standards of professional nursing; and all federal, state, and local laws, rules, and regulations affecting the advanced role and specialty area. When collaborating with other health care providers, the advanced practice nurse shall be accountable for knowledge of the statutes and rules relating to advanced practice nursing and function within the boundaries of the appropriate advanced practice category.

(b) The advanced practice nurse shall practice within the advanced specialty and role appropriate to his/her advanced educational preparation.

(c) The advanced practice nurse acts independently and/or in collaboration with the health team in the observation, assessment, diagnosis, intervention, evaluation, rehabilitation, care and counsel, and health teachings of persons who are ill, injured or infirm or experiencing changes in normal health processes; and in the promotion and maintenance of health or prevention of illness.

(d) When providing medical aspects of care, advanced practice nurses shall utilize mechanisms which provide authority for that care. These mechanisms may include, but are not limited to, Protocols or other written authorization. This shall not be construed as requiring authority for nursing aspects of care.

[*MY COMMENT*: Note well that this directly and unequivocally states that they do not have direct authority for medical care under the Texas statute.]

(1) Protocols or other written authorization shall promote the exercise of professional judgment by the advanced practice nurse commensurate with his/her education and experience. The degree of detail within protocols/policies/practice guidelines/clinical practice privileges may vary in relation to the complexity of the situations covered by such Protocols, the advanced specialty area of practice, the advanced educational preparation of the individual, and the experience level of the individual advanced practice nurse.

(2) Protocols or other written authorization:

(A) should be jointly developed by the advanced practice nurse and the appropriate physician(s),

(B) shall be signed by both the advanced practice nurse and the physician(s),

(C) shall be reviewed and re-signed at least annually,

(D) shall be maintained in the practice setting of the advanced practice nurse, and

(E) shall be made available as necessary to verify authority to provide medical aspects of care.

(e) The advanced practice nurse shall retain professional accountability for advanced practice nursing care.

http://www.bne.state.tx.us/rr221.htm

Originally posted by MacGyver
Here's more proof from California...

I'm not going to bother looking up California... I've proven the point with Texas. (I love how these nurse organizations try to put a spin on their true level of authorization to provide medical care.)

Originally posted by MacGyver
BTW, CRNAs do NOT get paid as much as MDAs:

http://www.nurseweek.com/features/00-02/anest.html

This is due to the extraordinarily high number of CRNAs who are currently marginalized in Anesthesiology practices (i.e., the anesthesiologist practice bills for their service and simplypays the CRNA a salary in return). But, then again, this really shouldn't be an issue since they can practice independently and form their own practice groups, right?

And, I've shown you at least one example (albeit anecdotal and unsuportable with a link... but I know it's true, if that counts) where a CRNA makes as much as an MDA. Plus, CRNA's salaries went up 16% between 2002-2003 and currently top $100K on average. Not a bad gig for half the training required of an MDA!

http://www.outpatientsurgery.net/2003/os01/news.php

Originally posted by MacGyver
More evidence of your ignorance regarding CRNA indepent practice:

CRNAs are the sole anesthesia providers in approximately 50% of all hospitals

http://www.nursesource.org/anesthetist.html

You raise a straw man. I never disputed that, or even brought it up for that matter. I have no doubts that, as technicians, CRNAs can provide an equivalent competency in the administration of anesthesia. What I'm saying is that a CRNA cannot practice without the supervision and authorization from a doctor in some way, shape, or form. No matter how you slice it, this is not "independent" practice. You can't refute that. Stop trying.

-Skip

 

[beezar]

Hey Macguyver,

Who are you? Are you a med student, surgeon, what?

And if you are not an anesthesiologist/thinking about becoming an anesthesiologist, why are you spending so much time researching on CRNA's vs. MDA's?

Don't you have anything else better to do?

Who are you?

 

[MacGyver]

Originally posted by Skip Intro
I'm not going to bother looking up California... I've proven the point with Texas.

Your point was that there were NO states that allowed CRNAs independent practice. You are wrong about that.

I love how these nurse organizations try to put a spin on their true level of authorization to provide medical care.

Well, for starters, they define anesthesia as NURSING, not medical care. Thats the reason why state nursing boards have sole authority in many states to regulate whatever they want to, and the state medical board has no say.

But, then again, this really shouldn't be an issue since they can practice independently and form their own practice groups, right?

Actually, there is evidence of collusion between MDA groups and hospitals to try and bar CRNA groups in some states. Several lawsuits against MDAs have been filed on anti-trust grounds, and of the lawsuits that have been resolved, all of them have been won by the CRNAs.

MDAs have a serious problem to deal with.

And, I've shown you at least one example (albeit anecdotal and unsuportable with a link... but I know it's true, if that counts) where a CRNA makes as much as an MDA.

Personal anecdotes dont count for jack. I have a personal anecdote that says a man was cured of deafness by spinal manipulation (i.e. AT Still case).

Plus, CRNA's salaries went up 16% between 2002-2003 and currently top $100K on average. Not a bad gig for half the training required of an MDA!

http://www.outpatientsurgery.net/2003/os01/news.php

So what. You said that CRNAs often make the same as MDAs. Thats patently false. Some CRNAs make more than MDAs, just as SOME MDs make more than 1 million a year. Outliers are poor evidence.

What I'm saying is that a CRNA cannot practice without the supervision and authorization from a doctor in some way, shape, or form. No matter how you slice it, this is not "independent" practice. You can't refute that. Stop trying.

Thats not true in most states.

Oregon:

http://www.oregon-crna.org/Information/Political/oregon opts out.htm

Since 1986 CRNAs have been able to bill as independent practitioners for their services under Medicare part B regulations. However facilities (hospitals) which bill under Medicare part A have been unable to bill for services provided by CRNA's working as licensed independent practitioners without a physician signature as the supervising practitioner. The op-out which was approved by the boards of medicine and nursing and has been signed by the governor now refers to state law as the source of such regulations. This does much to clarify the standing of CRNAs as independent practitioners in our state.

http://www.oregon-crna.org/1997 Leg...998 Opinion of CRNA scope of Practice.doc.htm

For example, ORS678255.2 to provide necessary post-anesthesia care services WITHOUT medical collaboration

http://www.oregon-crna.org/Information/Public Information/about_crnas.htm

CRNA's practice in a variety of arrangements in the metropolitan area. In hospitals they may practice independently, or they may practice in a CRNA/Anesthesiologist collaborative manner. CRNA's also practice in dental and medical offices in the metro area.

 

[IsoGirl2707]

Does anyone know the differences in malpractice premiums that CRNA's vs. MDAs pay? From what I understand, CRNA's have extremely low malpractice premiums while MDA's have better premiums than say 10 years ago but they are still high.

And I must say, coming from the midwest and having worked in both rural and urban areas with CRNA's, most make well over the median salary of $88,000. Those who are making $88,000 work only 2-3 days per week.

 

[Skip Intro]

Originally posted by MacGyver
Your point was that there were NO states that allowed CRNAs independent practice. You are wrong about that.

They don't.

Originally posted by MacGyver
Well, for starters, they define anesthesia as NURSING, not medical care. Thats the reason why state nursing boards have sole authority in many states to regulate whatever they want to, and the state medical board has no say.

Okay, and as I said already, I don't dispute the fact that, as techicians, CRNA's can pass gas just as well as an MDA. But, you are just patently wrong and showing your utter ignorance when you assert that nursing boards can do "whatever they want to" and the state medical board "has no say." Do you make this stuff up as you go?

Originally posted by MacGyver
Actually, there is evidence of collusion between MDA groups and hospitals to try and bar CRNA groups in some states. Several lawsuits against MDAs have been filed on anti-trust grounds, and of the lawsuits that have been resolved, all of them have been won by the CRNAs.

Show me a list. I can't comment on your unsupported suppositions.

Originally posted by MacGyver
MDAs have a serious problem to deal with.

Your personal opinion duly noted.

Originally posted by MacGyver
Personal anecdotes dont count for jack. I have a personal anecdote that says a man was cured of deafness by spinal manipulation (i.e. AT Still case).

I agree. I offered with the full disclaimer.

Originally posted by MacGyver
So what. You said that CRNAs often make the same as MDAs. Thats patently false. Some CRNAs make more than MDAs, just as SOME MDs make more than 1 million a year. Outliers are poor evidence.

No, I believe I said...

I can't understand why this is perceived as such a turf war. The "team approach" has to do more with Medicare's antiquated third-party billing structure, which many insurance companies model as well. Still, if money is the impetus for the turf war, I personally know of a CRNA who got a job last year in the midwest with a salary of $311,000 year! I fundamentally agree with the point you're trying to make, though.
...
The fact is, if there are enough jobs for MDAs and CRNAs, then so be it. Let them have their rights. When push comes to shove, though, an MD will be hired over a CRNA any day of the week... especially given (as I exemplified above) the salaries that CRNAs themselves are now pulling down, which are for the most part equivalent to MDAs.

... I never said they make as much grossly, especially if you choose to ignore workload factor and marginalization. The fact that there is now equvilancey in third-party billing as well as the fact that CRNA's can bill at the same rate as an MDA for a procedure means they are equivalent (or have the potential to be). My statement is NOT patently false; you just don't (or didn't) consider the fact that many (if not most) CRNA's work directly for anesthesiologists, as I also previously mentioned and you either ignored or didn't want to comment on.

The rest of my post that you chose not to comment on I'll take as a concession.

As far as Oregon, so they can bill under part B of Medicare which covers physician charges. So can physical and occupational therapists. So can chiropractors. Big deal. What does this prove?

 

[MacGyver]

Another thing you need to understand is the states THAT DO mention some kind of "physician supervision" are referring to either surgeon OR MDA. There is no state which REQUIRES MDAs to supervise CRNAs. Even in the states that do have collaboration/supervision requirements, the surgeon is fully capable of serving as supervisor over the CRNA. Either way, it cuts MDAs out of the loop.

Other states involved:

New Mexico: http://www.aana.com/press/2002/110102.asp

Governor Gary Johnson has informed the Centers for Medicare & Medicaid Services (CMS) that New Mexico is opting out of the physician supervision requirement for nurse anesthetists because it "is in the best interests of New Mexico?s citizens, rural communities and hospitals." The opt-out is effective immediately. Many of New Mexico?s hospitals rely solely on CRNAs to provide safe anesthesia care to patients.

New Hampshire: http://www.aana.com/press/2002/061102.asp

New Hampshire becomes the fifth state to remove the federal physician supervision requirement since CMS published its anesthesia care rule granting states the ability to seek such an opt-out.

California: http://www.canainc.org/members/crna-prectice-book.htm

Legal Basis of Nurse Anesthesia Practice in California.

The Board of Registered Nursing is the authority on CRNA scope of practice.

CRNA's do not require physician supervision or physician signature of documents.

CRNA's select and administer the full range of drugs and techniques.

CRNA's practice in all settings: large institutions, ambulatory surgery centers, and office settings delivering monitored anesthesia care, regional & general anesthesia, and pain management services"

Kansas: http://www.kana.org/pdf/AnesthCovMap03.pdf

In this map showing a county breakdown of CRNAs vs MDAs, CRNAs provide EXCLUSIVE anesthesia services in over 70% of the counties.

 

[Skip Intro]

Originally posted by MacGyver
More evidence for Skip...

You know, MacGuyver, I don't really know what your point is. Are you trying to suggest that CRNA's are replacing MDAs? Are you suggesting that there is no longer a need for MDAs? I can't really figure out what argument you're trying to make. And, you haven't effectively refuted me. Despite what you are trying to argue about supervised (or lack thereof) actions in the OR or doctor's office, you cannot argue that CRNAs are legally allowed to practice independently. If you're saying that they are allowed to practice nursing aspects of anesthesia independently (and not medicine aspects) and to administer the technical aspects of anesthesia (and not medicine aspects) without being checked-off by an MDA or other physician in many states, then of course. No one is arguing that point. If you are suggesting, OTOH, that they can practice independently other than the aforementioned, then you are quite simply wrong.

CRNAs are no threat to MDAs. There will always be a need for both. I've never in this thread argued against that point, but you're attempting to make (I think, because I'm not really sure what your point is) some wild assumptions to the contrary backed up by your continuously tautologous and therefpre meaningless arguments. And, as I recall from previous debates with you, you only pick and snip parts of responses that you feel you can respond to, in a very trollish manner, continuing to makie counterassertions that have already been addressed, which you apparently either don't understand or don't read.

Don't you have better things to do?

-Skip

 

[MacGyver]

If you're saying that they are allowed to practice nursing aspects of anesthesia independently (and not medicine aspects) and to administer the technical aspects of anesthesia (and not medicine aspects) without being checked-off by an MDA or other physician in many states, then of course. No one is arguing that point. If you are suggesting, OTOH, that they can practice independently other than the aforementioned, then you are quite simply wrong.

Now you are guilty of playing word games just like the CRNAs.

There is no effective difference between "medical" anesthesia and "nursing" anesthesia, other than post-op care. During the actual surgery, medical = nursing anesthesia.

The two are functionally equivalent. If that was not so, how in the HELL do you explain the statistics regarding thousands of hospitals who do surgeries but dont hire a single MDA and instead hire CRNAs?

You tried to claim that there are no states which allow independent practice rights for CRNAs (i.e. no doc supervision, no doc collaboration, no pre-signed doc agreement, no doc in the hospital, etc). Thats totally wrong.

Yes, CRNAs dont run gas for super specialized surgeries in most places, but they ROUTINELY work independently regarding bread and butter surgeries.

Here's yet another link for you. Note: the author of this article uses physicians in the very broadest of senses (i.e. surgeons as well as MDAs).

http://www.denverpost.com/Stories/0,1413,36~33~1407167,00.html

Nurses across Colorado can administer anesthetics without physician supervision, the state board of health ruled Wednesday.

Gov. Bill Owens asked state officials to allow nurse anesthetists to practice independently because of a shortage of anesthesiologists in rural Colorado communities. The federal government recently allowed states to opt out of a rule that required hospital physicians to supervise nurse anesthetists to get paid.

 

[Skip Intro]

Originally posted by MacGyver

If you're saying that they are allowed to practice nursing aspects of anesthesia independently (and not medicine aspects) and to administer the technical aspects of anesthesia (and not medicine aspects) without being checked-off by an MDA or other physician in many states, then of course. No one is arguing that point. If you are suggesting, OTOH, that they can practice independently other than the aforementioned, then you are quite simply wrong.

Now you are guilty of playing word games just like the CRNAs.

There is no effective difference between "medical" anesthesia and "nursing" anesthesia, other than post-op care. During the actual surgery, medical = nursing anesthesia.

The two are functionally equivalent. If that was not so, how in the HELL do you explain the statistics regarding thousands of hospitals who do surgeries but dont hire a single MDA and instead hire CRNAs?

You tried to claim that there are no states which allow independent practice rights for CRNAs (i.e. no doc supervision, no doc collaboration, no pre-signed doc agreement, no doc in the hospital, etc). Thats totally wrong.

Yes, CRNAs dont run gas for super specialized surgeries in most places, but they ROUTINELY work independently regarding bread and butter surgeries.

Here's yet another link for you. Note: the author of this article uses physicians in the very broadest of senses (i.e. surgeons as well as MDAs).

http://www.denverpost.com/Stories/0,1413,36~33~1407167,00.html

Nurses across Colorado can administer anesthetics without physician supervision, the state board of health ruled Wednesday.

Gov. Bill Owens asked state officials to allow nurse anesthetists to practice independently because of a shortage of anesthesiologists in rural Colorado communities. The federal government recently allowed states to opt out of a rule that required hospital physicians to supervise nurse anesthetists to get paid.

You are continuously (purposefully or not) mistaking this "supervision" issue as meaning that a CRNA can act independently. They cannot. A doctor may not be looking over their shoulder watching everything they do and may not have to sign-off on their procedure, but one must be present (meaning an order for anesthesia is made by a physician), whether a surgeon or not, when anesthesia is administered! You cannot refute this. Until the day that a nurse anesthetist opens up his or her own office and administers anesthesia on his or her own, then you cannot say that CRNA's operate independently. What will convince me that I'm wrong? If a CRNA specializing in pain management is allowed to administer blocks or prescribe medications, without physician sign-off, in his or her own clinic. Until then, you are misrepresenting (as the AANA does) the law!

And to further my point, the article you reference above (for anyone who clicks and reads it, and I suggest they should) undermines and refutes - with these two extremely limited exceptions (New Hampshire and rural Colorado) - everything you've argued to this point! Again, and as I said before, what is the point of your joining this discussion? Can you succinctly state exactly what your agenda in wasting all of this time is? Are you suggesting that CRNAs are going to replace MDAs? If that's really what you're trying to intimate, I believe you're off your rocker.

-Skip

 

[Skip Intro]

Originally posted by MacGyver
The rest of the states allow CRNAs to run gas without any kind of relationship AT ALL to an MDA.

A DOCTOR HAS TO BE PRESENT!!!! Never once did I say exclusively an MDA had to be present. You are putting words into my mouth. Did you ACTUALLY READ what I wrote above?!?!??

Originally posted by MacGyver
Its not uncommon to find gas practices that are 100% staffed by CRNAs that have exclusive contracts with hospitals.

THEY CANNOT PRACTICE ANESTHESIOLOGY WITHOUT SOME FORM OF DOCTOR PRESENT!!! I've said this repeatedly above. How many more times do I have to say it before you get it?!??!?? THEY CANNOT PRACTICE INDEPENDENTLY!! CRNA is a NURSING specialty!!

-Skip

 

[Skip Intro]

MacGyver deleted his post that I referenced as I was typing my response to it! How typical. When cornered with facts, run away.

 

[Skip Intro]

Here's the current Federal Law (my bolding and underlining for emphasis):

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CMS Conditions of Participation re: Anesthesia Services
Effective November 13, 2001

Ambulatory Surgical Centers (42 C.F.R. ? 416.42)

(a) Standard: Anesthetic risk and evaluation. A physician must examine the patient immediately before surgery to evaluate the risk of anesthesia and of the procedure to be performed. Before discharge from the ASC, each patient must be evaluated by a physician for proper anesthesia recovery.

(b) Standard: Administration of anesthesia. Anesthesia must be administered by only -

(1) A qualified anesthesiologist; or
(2) A physician qualified to administer anesthesia, a certified registered nurse anesthetist (CRNA) or an anesthesiologist's assistant as defined in ?410.69(b) of this chapter, or a supervised trainee in an approved educational program. In those cases in which a non-physician administers the anesthesia, unless exempted in accordance with paragraph (d) of this section, the anesthetist must be under the supervision of the operating physician, and in the case of an anesthesiologist's assistant, under the supervision of an anesthesiologist.

(c) Standard: Discharge. All patients are discharged in the company of a responsible adult, except those exempted by the attending physician.

(d) Standard: State exemption. (1) An ASC may be exempted from the requirement for physician supervision of CRNAs as described in paragraph (b)(2) of this section, if the State in which the ASC is located submits a letter to CMS signed by the Governor, following consultation with the State's Boards of Medicine and Nursing, requesting exemption from physician supervision of CRNAs. The letter from the Governor must attest that he or she has consulted with the State Boards of Medicine and Nursing about issues related to access to and the quality of anesthesia services in the State and has concluded that it is in the best interest of the State's citizens to opt-out of the current physician supervision requirement and that the opt-out is consistent with State law.

(2) The request for exemption and recognition of State laws, and the withdrawal of the request may be submitted at any time, and are effective upon submission.

[*MY COMMENT*: Note that state exemptions have been granted only twice so far - in Colorado and in New Hampshire.]

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Hospitals (42 C.F.R. ? 482.52)

If the hospital furnishes anesthesia services, they must be provided in a well organized manner under the direction of a qualified doctor of medicine or osteopathy. If outpatient services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered.

(a) Standard: Organization and staffing. The organization of the anesthesia services must be appropriate to the scope of services offered. Anesthesia must be administered only by -

(1) A qualified anesthesiologist;
(2) A doctor of medicine or osteopathy (other than an anesthesiologist);
(3) A dentist, oral surgeon, or podiatrist who is qualified to administer anesthesia under State law;
(4) A certified registered nurse anesthetist (CRNA), as defined in ? 410.69(b) of this chapter, who, unless exempted in accordance with paragrpah (c) of this section, is under the supervision of the operating practitioner or an anesthesiologist who is immediately available if needed; or
(5) An anesthesiologist's assistant, as defined in ? 410.69(b) of this chapter, who is under the supervision of an anesthesiologist who is immediately available if needed.

(b) Standard: Delivery of services. Anesthesia services must be consistent with needs and resources. Policies on anesthesia procedures must include the delineation of preanesthesia and post anesthesia responsibilities. The policies must ensure that the following are provided for each patient:

(1) A preanesthesia evaluation by an individual qualified to administer anesthesia under paragraph (a) of this section performed within 48 hours prior to surgery.
(2) An intraoperative anesthesia record.
(3) With respect to inpatients, a postanesthesia followup report by the individual who administers the anesthesia that is written within 48 hours after surgery.
(4) With respect to outpatients, a postanesthesia evaluation for proper anesthesia recovery performed in accordance with policies and procedures approved by the medical staff.
(c) Standard: State exemption.

(1) A hospital may be exempted from the requirement for physician supervision of CRNAs as described in paragraph (a)(4) of this section, if the State in which the hospital is located submits a letter to CMS signed by the Governor, following consultation with the State's Boards of Medicine and Nursing, requesting exemption from physician supervision of CRNAs. The letter from the Governor must attest that he or she has consulted with the State Boards of Medicine and Nursing about issues related to access to and the quality of anesthesia services in the State and has concluded that it is in the best interest of the State's citizens to opt-out of the current physician supervision requirement and that the opt-out is consistent with State law.
(2) The request for exemption and recognition of State laws, and the withdrawal of the request may be submitted at any time, and are effective upon submission.

[*MY COMMENT*: Note that state exemptions have been granted only twice so far - in Colorado and in New Hampshire.]

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Critical Access Hospitals (42 C.F.R. ? 485.639)

Surgical procedures must be performed in a safe manner by qualified practitioners who have been granted clinical privileges by the governing body of the CAH in accordance with the designation requirements under paragraph (a) of this section.

(a) Designation of qualified practitioners. The CAH designates the practitioners who are allowed to perform surgery for CAH patients, in accordance with its approved policies and procedures, and with State scope of practice laws. Surgery is performed only by -


(1) A doctor of medicine or osteopathy, including an osteopathic practitioner recognized under section 1101a)(7) of the Act;
(2) A doctor of dental surgery or dental medicine; or
(3) A doctor of podiatric medicine.
(b) Anesthetic risk and evaluation.

(1) A qualified practitioner, as specified in paragraph (a) of this section, must examine the patient immediately before surgery to evaluate the risk of the procedure to be performed.

(2) A qualified practitioner, as specified in paragraph (c) of this section, must examine each patient before surgery to evaluate the risk of anesthesia.(3) Before discharge from the CAH, each patient must be evaluated for proper anesthesia recovery by a qualified practitioner as described in paragraph (c) of this section.
(c) Administration of anesthesia. The CAH designates the person who is allows to administer anesthesia to CAH patients in accordance with its approved policies and procedures and with State scope-of-practice laws.

(1) Anesthetics must be administered only by -- (i) A qualified anesthesiologist; (ii) A doctor of medicine or osteopathy other than an anesthesiologists, including an osteopathic practitioner recognized under section 1101(a)(7) of the Act; (iii) A doctor of dental surgery or dental medicine; (iv) a doctor of podiatric medicine; (v) A certified registered nurse anesthetist (CRNA), as defined in ? 410.69(b) of this chapter; (vi) An anesthesiologist's assistant, as defined in ? 410.69(b) of this chapter; or (vii) A supervised trainee in an approved educational program, as described in ?? 413.85 or 413.86 of this chapter.


(2) In those cases in which a CRNA administers the anesthesia, the anesthetist must be under the supervision of the operating practitioner except as provided in paragraph (e) of this section. An anesthesiologist's assistant who administers anesthesia must be under the supervision of an anesthesiologist.
(d) Discharge. All patients are discharged in the company of a responsible adult, except those exempted by the practitioner who performed the surgical procedure.

(e) Standard: State exemption. (1) A CAH may be exempted from the requirement for physician supervision of CRNAs as described in paragraph (c)(2) of this section, if the State in which the CAH is located submits a letter to CMS signed by the Governor, following consultation with the State's Boards of Medicine and Nursing, requesting exemption from physician supervision of CRNAs. The letter from the Governor must attest that he or she has consulted with the State Boards of Medicine and Nursing about issues related to access to and the quality of anesthesia services in the State and has concluded that it is in the best interest of the State's citizens to opt-out of the current physician supervision requirement and that the opt-out is consistent with State law.

(2) The request for exemption and recognition of State laws, and the
withdrawal of the request may be submitted at any time, and are effective upon submission.

[*MY COMMENT*: Note that state exemptions have been granted only twice so far - in Colorado and in New Hampshire.]

http://www.asahq.org/Washington/narules.htm

 

[HowUdoin]

Very impressive Skip.

 

[MacGyver]

Skip Intro,

Given that you've shifted the argument from MDA supervision to surgeon supervision (which has nothing to do with MDAs in the first place), you need to concede the following:

CRNAs in many states are allowed to administer gas 100% independently from an MDA.

You cant dispute that, so you play word games with "well the surgeon still gets to supervise."

SO WHAT IF THE SURGEON GETS TO SUPERVISE? WHAT THE HELL DOES THAT HAVE TO DO WITH MDAs????

No MDA is needed for CRNAs to practice. You've made an argument for surgeon's authority over CRNAs, but that is irrelevant to the MDA community.

 

[MacGyver]

Originally posted by Skip Intro
And, this was interesting...


http://rebel.212.net/mhcrg/tabb,partII.htm

You'd think that if patients were really at risk they'd actually publish their findings and do a study. Instead they make allegations based on personal anecdotes and no data which can be verified and shown to all.

If the ASA/MDA community had one tenth the political savvy and proactive leadership that the CRNA associations have, this would never have been an issue. Instead, the ASA/MDA groups have sit on their ass just assuming that their turf was never going to be in doubt. What outrageously stupid fools.

 

[MacGyver]

Originally posted by Skip Intro

You are continuously (purposefully or not) mistaking this "supervision" issue as meaning that a CRNA can act independently. They cannot. A doctor may not be looking over their shoulder watching everything they do and may not have to sign-off on their procedure, but one must be present (meaning an order for anesthesia is made by a physician), whether a surgeon or not, when anesthesia is administered!

I just assumed that this being an ANESTHESIOLOGY FORUM, that MDA supervision, not surgeon supervision was the important concept involved.

Bravo, you've proved in that in SOME STATES, surgeons supervise CRNAs. Now you tell me why this makes the CRNA situation better from an MDA standpoint.

You cannot refute this. Until the day that a nurse anesthetist opens up his or her own office and administers anesthesia on his or her own, then you cannot say that CRNA's operate independently.

Fine, then I'll say this: CRNAs operate INDEPENDENTLY FROM MDAs in many states. Is that better?

What will convince me that I'm wrong? If a CRNA specializing in pain management is allowed to administer blocks or prescribe medications, without physician sign-off, in his or her own clinic. Until then, you are misrepresenting (as the AANA does) the law!

Now you are shifting the goalposts. First you said that CRNAs are not allowed to run gas independently. Now you are saying that they arent allowed to work independently specifically as pain management specialists. First, I'm pretty sure I can find an example of a state in which CRNAs are in fact allowed to run their own pain practice with no MD oversight. But thats really besides the fact. The VAST majority of MDA practice is devoted to running gas during surgeries, not pain management. If you are content to allow the CRNAs to reduce market share of MDAs to 10% of their current scope, then fine.

And to further my point, the article you reference above (for anyone who clicks and reads it, and I suggest they should) undermines and refutes - with these two extremely limited exceptions (New Hampshire and rural Colorado)

Wait a minute. You're the one who said there's not a single state which allows independent CRNA practice. You forced me to concede that surgeons in some states get to supervise CRNAs. Now you must concede that you were in fact WRONG when you said that "no state" allows CRNA independent practice.

 

[MacGyver]

The fact is, if there are enough jobs for MDAs and CRNAs, then so be it. Let them have their rights. When push comes to shove, though, an MD will be hired over a CRNA any day of the week... especially given (as I exemplified above) the salaries that CRNAs themselves are now pulling down, which are for the most part equivalent to MDAs

And what if there is not? Do you really think that MDAs are going to be successful in closing pandora's box and restricting CRNA practice to the "good ole days?"

thats a joke. Once you give the CRNAs privileges, the chances of them being revoked are nil. Nothing short of massive numbers of patient deaths would do it.

Again, CRNA salaries are in no way "equivalent" to MDA salaries. The mean/medians of both groups differ by more than a standard deviation.

But dont let faulty logic stop you. After all, I know a nurse who makes more than an FP MD, therefore its common for nurses to make more than FP MDs right?

 

[MacGyver]

You are also wrong when you state that only Colorado and New Hampshire have opted out. Currently, there are 10 states which have opted out and allow independent CRNA practice to recover Medicare/Medicaid reimbursements.

Thats 10 states in the span of 2 years since they put in the state "opt out" clause. You do the math.

 

[voltron]

I think Mac is a pre-med. I mean if you've spent any time in the OR then you would know that not a single surgeon I've ever met or worked with would feel comfortable supervising a CRNA?!!? Are you kidding me? Thats gotta be one of the stupidest things I've ever heard. Not that surgeons aren't smart, its just that they're not trained in that. And I go to a top ranked academic medical center for medical school, and I've seen NP's do entire surgeries by themselves from start to finish with no supervision at all. I've seen it in private practice too. So Mac you are a huge loser who lost this argument hands down to skip, everybody knows it, so keep posting your dumb threads, they just make you look more stupid. *****.

 

[BeefyRedEye]

McGuyver - PLEASE JUST GO AWAY - I like to read this forum for information and advice as an upcoming anesthesia resident but your endless rants about the same topic are juvenile and frankly extremely annoying. I am speaking for many others on this forum: go back to your own forum, under your little rock, and get a life.

 

[MacGyver]

Originally posted by voltron
not a single surgeon I've ever met or worked with would feel comfortable supervising a CRNA

I'm not telling you what surgeons are comfortable with, I'm telling you what the law/regulations are in many states.

Isnt this a huge indictment of the MDA specialty? What the ****???

Have you ever heard of an oncologist supervising a rad onc? Or an endocrinologist supervising an IM doc? Further evidence that MDAs have done a very poor job protecting their profession.

Nevertheless, you cant dispute the statistics that there are THOUSANDS of hospitals across the US that use CRNAs only, without a single MDA on staff. These CRNAs run gas for surgeries just like MDAs do, so you are obviously wrong when you say that "surgeons arent comfortable supervising CRNAs." The fact is, they can and ARE doing this nationwide.

Skip Intro doesnt seem to get the fact that this cuts MDAs out of the loop. Just because MDAs still have a monopoly over pain medicine doesnt mean it will always be that way. Intro's attitude of "well it wont affect what I want to do as an MDA so its irrelevant" is the same naive attitude held by MDAs for years that gave CRNAs the opening they needed to encroach the profession.

its just that they're not trained in that.

Trained or not, they still "supervise" CRNAs, at least thats what Skip INtro would have you believe. Personally, I think this surgeon supervision is a smokescreen. I bet if you walked into one of the CRNA-only hospitals, you would find VERY LITTLE supervision going on.

And I go to a top ranked academic medical center for medical school, and I've seen NP's do entire surgeries by themselves from start to finish with no supervision at all.

Thats bull****, unless you are defining "surgery" as some superficial skin procedure. There is not a single state in the nation which allows, under any circumstances for NPs or PAs to run whole surgeries on their own with no MD supervision.

Please, give me the name of this program and their location, so I can report them to your state medical board for breaking regulations. Because if what you say is true, they are in fact breaking the rules.

So Mac you are a huge loser who lost this argument hands down to skip, everybody knows it

Really? Skip Intro showed that technically some states have a provision that docs must supervise CRNAs, but that MDAs are NOT required in any way for supervision.

From a surgeon's standpoint, thats great. From an MDAs standpoint, its irrelevant because they are essentially cut out of the loop.

You are obviously a very angry person, I get the feeling that you know what I say is true and you are a future MDA who is worried. Well, you should be.

 

[jahan22]

I am a future MDA, I am in fact not worried at all, and I think that you may actually be the angry one. How much of your life do you waste going on those CRNA boards, cutting and pasting articles, rebutting other people's posts? Typing furiously on your keyboard, getting a hard on while thinkng about how you'll amaze and stun everyone on this board with your quick wit, and concise arguments. I still stand by what I said, you are possibly the biggest loser on the face of this planet.

 

[beezar]

Hey Macguyver,

Still haven't answered my question. Or are you afraid of something? Who are you, what do you do, and how do you have so much time to look up all that crap you do?

Got something to hide?

 

[Drakensoul]

Soap Opera Music Plays...
As the World Turns!

*Popcorn*

 

[2bkiddoc]

Damn, i was exicted to read the first post cause im really interested to hear the +/- of gas from the SDNers... but then it turned into two other threads ive read on here....

think i could re-claim skip's post???

1) Good
2) Bad (without falling back into an -impressive, insightful, and informative- discussion about you-know-what?)

thnx! thought id give it a whirl...

 

[BassDominator]

Good: Patient advocacy and comfort are job #1. It's exciting, challenging, and more than just putting people to sleep. There's lots of cool subspecialties: pain, ICU, pediatrics, cardiac, etc. Cool technology and procedures. You can work as little or as much as you like and still make a good living. You keep the surgeons and other docs from killing people.

Bad: The surgeons take all the credit or blame you when they screw up. The surgeons treat you like a nurse.

 

[TheDoctorBen]

Interesting argument.

 

[bgreet]

MacGyver go away

 

[NaeBlis]

MacGyver go away

You should pay attention to the time stamps, mac hasn't been here since march.