crna making 120000 to 180000

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The bill approved by Clinton allows states to individually opt out of a requirement that CRNAs must have direct supervision by MDAs. To date, four states (Nebraska, Iowa, Minnesota, and I believe Idaho) have elected to opt out and now allow CRNAs to work without MDA supervision. The reasoning for this was many states have hospitals with severe shortages of MDAs. This bill allows CRNAs to provide anesthesia to help fill the void at these hospitals. Personally, I don't feel this is the best answer, but I don't have a good alternative in mind. Maybe with the growing numbers of MD/DO's who will be completing residency in the next 4-5 years this shortage will be filled by MDAs and CRNAs will get squeezed out of the picture somewhat.
As for level of training, sure CRNAs don't have the amount of education that MDAs do. But the CRNAs, like NPs and PAs, have adequate training to be proficient in their roles.
Members don't see this ad.
 
And that is why we are gonna vote Clinton right outta office!! Yeah!! wait...he is out of office.

Anyway, we brought this problem on ourselves, we are to blame. We looked the other way and thought "hell, this is a good way to make money!". It happened with HMO's when they were starting up, it happened with NP's, PA's and now CRNA's. We have no one but ourselves to blame...and WE MUST BE THE SOLUTIONS. Strong representation in the AMA, in PAC's and specialty Colleges is the way. Hell...run for local government!
Bitching and moaning makes you look bad.
 
I agree with both of you. And I firmly believe that physicians must stand up and fight for themselves. I also agree that bitching and moaning is futile. As far as Clinton being out of office, that's only partially true. His more radical wife is in a pretty powerful position, and if she had her way, physicians would be salaried employees of the government. I deeply apologize for another political statement. And to think that I generally hate discussing politics!
 
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•••quote:•••Originally posted by halothane:
• And some idiot wants to do a spell check on my post....looks like you are not even fit to be nurse...a secretary's job will be appropriate!! for you to be soo thrilled at spotting trivial syntax errors.•••••hmmm, that wasn't about you.
 
History of Nurse Anesthesia Practice

Nurses were the first professional group to provide anesthesia services in the United States. Established in the late 1800s, nurse anesthesia has since become recognized as the first clinical nursing specialty. The discipline of nurse anesthesia developed in response to surgeon requests of seeking a solution to the high morbidity and mortality attributed to anesthesia at that time. Surgeons saw nurses as a cadre of professionals who could give their undivided attention to patient care during surgical procedures. Serving as pioneers in anesthesia, nurse anesthetists became involved in the full range of specialty surgical procedures, as well as in the refinement of anesthesia techniques and equipment.

The earliest existing records documenting the anesthetic care of patients by nurses were those of Sister Mary Bernard, a Catholic nun who assumed her duties at St. Vincent's Hospital in Erie, Pennsylvania in 1887. The most famous nurse anesthetist of the nineteenth century, Alice Magaw, worked at St. Mary's Hospital (1889), in Rochester, Minnesota. That hospital, established by the Sisters of St. Francis and operated by Dr. William Worrell Mayo, later became internationally recognized as the Mayo Clinic. Dr. Charles Mayo conferred upon Alice Magaw the title of "mother of anesthesia," for her many achievements in the field of anesthesiology, particularly her mastery of the open-drop inhalation technique of anesthesia utilizing ether and chloroform and her subsequent publishing of her findings.

Together, Dr. Mayo and Ms. Magaw were instrumental in establishing a showcase of professional excellence in anesthesia and surgery. Hundreds of physicians and nurses from the United States and throughout the world came to observe and learn their anesthesia techniques. Alice Magaw documented the anesthesia practice outcomes at St. Mary's Hospital and reported them in various medical journals between 1899 and 1906. In 1906, one article documented more than 14,000 anesthetics without a single complication attributable to anesthesia. (Surgery, Gynecology and Obstetrics, 3:795.)

In 1909, the first formal educational programs preparing nurse anesthetists were established. In 1914, Dr. George Crile and his nurse anesthetist, Agatha Hodgins, who became the founder of the American Association of Nurse Anesthetists (AANA), went to France with the American Ambulance group to assist in planning for the establishment of hospitals that would provide for the care of the sick and wounded members of the Allied Forces. While there, Hodgins taught both physicians and nurses from England and France how to administer anesthesia.

Since World War I, nurse anesthetists have been the principal anesthesia providers in combat areas of every war in which the United States has been engaged. During the Panama action, only nurse anesthetists were sent with the fighting forces. Nurse anesthetists have been held as prisoners of war, suffered combat wounds during wartime service, and have lost their lives serving their country. The names of two CRNAs killed in the Vietnam War are engraved on the Vietnam Memorial Wall in Washington, DC. Military nurse anesthetists have been honored and decorated by the United States and foreign governments for outstanding achievements, dedication to duty, and competence in treating the seriously wounded.

Although nurse anesthesia educational programs existed prior to World War I, the war sharply increased the demand for nurse anesthetists and, consequently, the need for more educational programs. Nurse anesthetists were often appointed as directors of anesthesia services in both the public and private sectors. In academic health centers, they were frequently responsible for the education of other nurses, medical interns, and physicians. Among the notable early programs of nurse anesthesia were: Johns Hopkins Hospital in Baltimore, the University Hospital of the University of Michigan in Ann Arbor, Charity Hospital in New Orleans, Barnes Hospital in St. Louis, and Presbyterian Hospital in Chicago. In 1922, Alice Hunt, a nurse anesthetist at Peter Bent Brigham Hospital in Boston, was invited by Dr. Samuel Harvey, professor of surgery, to join the Yale Medical School faculty as an instructor of anesthesia with academic rank. She accepted that position, eventually retiring from that institution in 1948.

Founded in 1931, the AANA is the professional association representing more than 27,000 nurse anesthetists nationwide. The AANA promulgates education, and practice standards and guidelines, and affords consultation to both private and governmental entities regarding nurse anesthetists and their practice. The AANA Foundation supports the profession through award of education and research grants to students, faculty, and practicing CRNAs.

The AANA developed and implemented a certification program in 1945 and instituted mandatory recertification in 1978. It established a mechanism for accreditation of nurse anesthesia educational programs in 1952, which has been recognized by the U.S. Department of Education since 1955. In 1975, the AANA was a leader among professional organizations in the United States by forming autonomous multidisciplinary councils with public representation for performing the profession's certification, accreditation, and public interest functions. Today, the CRNA credential is well recognized as an indicator of quality and competence.

The national office of the American Association of Nurse Anesthetists is located in Park Ridge, Illinois. The Association's federal affairs office is maintained in Washington, DC.

References
Bankert, M. Watchful Care: A History of America's Nurse Anesthetists. New York: Continuum. 1989.

Thatcher VS. History of Anesthesia with Emphasis on the Nurse Specialist. Philadelphia: JB Lippincott Company. 1953.
 
Nurse Anesthetists and Anesthesiologists Practicing Together

Anesthesia is a recognized specialty in both medicine and nursing. Approximately 80% of Certified Registered Nurse Anesthetists (CRNAs) work as partners in care with anesthesiologists, while the remaining 20% function as sole anesthesia providers working and collaborating with surgeons and other licensed physicians. THE AMERICAN ASSOCIATION OF NURSE ANESTHETISTS (AANA) SUPPORTS BOTH PRACTICE MODELS AND BLEIEVES THAT QUALITY OUTCOMES ARE EXCELLENT IN BOTH.

THE AANA SUPPORTS MUTUAL RESPECT AND OPEN FORTHRIGHT RELATIONS BETWEEN CRNAS AND ANESTHESIOLOGISTS WORKING IN A COLLABORATIVE FASHION.

It seems as if the ASA isn't in agreement with this statement

When CRNAs and anesthesiologists work together to provide patient care, the following are key concepts:

CRNAs are responsible for their actions in the care of patients and in the provision of anesthesia services.
CRNAs practice according to their licensure, certification and expertise.
The anesthesiologist is the medical specialist who provides perioperative services and functions collaboratively with the CRNA in the provision of anesthesia and related services.
Patient care needs should dictate appropriate personnel resources of both anesthesiologists and CRNAs, rather than predetermined numerical ratios.
The anesthesia and related services provided by either the CRNA or the anesthesiologist when working together include, but are not limited to:

Performing and documenting a pre-anesthetic assessment and evaluation of the patient, including ordering and administering pre-anesthetic medications, and requesting consultations and diagnostic studies.
Developing and implementing the anesthesia care plan.
Selecting and initiating the planned anesthetic technique which may include general, regional, or local anesthesia, or sedation.
Selecting and administering anesthetics and adjunct drugs and monitoring the patient's responses to surgery or anesthesia.
Selecting, applying, and inserting appropriate non-invasive and invasive monitoring modalities for continuous evaluation of the patient's physical status.
Managing the patient's airway and pulmonary status.
Managing emergence and recovery from anesthesia.
Providing post-anesthesia follow-up evaluation and care, including discharge of patients from a post-anesthesia care area.
Ordering, initiating or modifying pain relief therapy.
Responding to emergency situations by providing airway management, administration of emergency fluids or drugs, and advanced cardiac life support techniques.
References
Nurse Anesthetists and Anesthesiologists Practicing Together. In: Professional Practice Manual for the Certified Registered Nurse Anesthetist. Position Statement No. 1.9. Park Ridge, Illinois: American Association of Nurse Anesthetists. Adopted August 1996. Revised November 1996.
 
Qualifications and Capabilities of the Certified Registered Nurse Anesthetist

Introduction
This document has been prepared by the American Association of Nurse Anesthetists (AANA) to provide information about the qualifications and capabilities of Certified Registered Nurse Anesthetists (CRNAs). The practice of anesthesia is a recognized specialty within the profession of nursing. As one of the first nursing specialty groups, CRNAs have a longstanding commitment to high standards in a demanding field. As independently licensed health professionals, CRNAs are responsible and accountable for their practice.

In order to be a Certified Registered Nurse Anesthetist one must:

1. Graduate from a nurse anesthesia educational program accredited by the Council on Accreditation of Nurse Anesthesia Educational Programs (COA) or its predecessor.

2. Pass the certification examination administered by the Council on Certification of Nurse Anesthetists or its predecessor.

Since its organization in 1931, the AANA has placed its responsibilities to the public above or equal to its responsibilities to its membership. The association has produced education and practice standards, implemented a certification process for nurse anesthetists (1945) and developed an accreditation program for nurse anesthesia education (1952). It was a leader in forming multidisciplinary councils with public representation to fulfill the profession's autonomous credentialing functions.

Over 27,000 CRNAs provide quality anesthesia care to more than 65% of all patients undergoing surgical or other medical interventions which necessitate the services of an anesthetist. In addition, CRNAs administer anesthesia for all types of surgical cases, from the simplest to the most complex. CRNAs are the sole anesthesia providers in two-thirds of rural hospitals in the United States. CRNAs work in every setting in which anesthesia is delivered: traditional hospital surgical suites and obstetrical delivery rooms, ambulatory surgical centers and the offices of dentists, podiatrists, and plastic surgeons.

Education of Nurse Anesthetists
The nurse anesthesia profession is known for its highly respected educational system and its strong commitment to quality education. There are over 80 nurse anesthesia educational programs in the United States today, all affiliated with, or operated by, universities. Approximately one-half of these programs are housed in schools of nursing, while the rest are in schools of health science or other appropriate graduate schools. The programs range from 24 to 36 months in length, depending upon university requirements, and all are at the master's degree level or higher. This sophisticated educational system provides over 2,000 enrolled students a graduate level science foundation along with clinical anesthesia experience to prepare them to become competent nurse anesthesia providers.

Academic Curriculum Requirements
The didactic curricula of nurse anesthesia programs are governed by COA standards and provide students the scientific, clinical, and professional foundation upon which to build sound and safe clinical practice. Most nurse anesthesia programs range from 45 to 75 graduate semester credits of courses pertinent to the practice of anesthesia. The science curriculum of graduate nurse anesthesia programs includes:

A minimum of 135 hours in Advanced Anatomy, Physiology and Pathophysiology.
A minimum of 90 hours in Advanced Pharmacology.
A minimum of 45 hours in Chemistry and Physics Related to Anesthesia.
The minimum requirement of 90 hours of courses in anesthesia practice provides content such as induction, maintenance, and emergence of anesthesia; airway management; anesthesia pharmacology; and anesthesia for special patient populations such as obstetrics, geriatrics, and pediatrics.
Most programs exceed these minimum requirements. In addition, many require study in methods of scientific inquiry and statistics, as well as active participation in student-generated and faculty-sponsored research.

Clinical residencies afford supervised experiences for students during which time they are able to learn anesthesia techniques, test theory, and apply knowledge to clinical problems. Students gain experience with patients of all ages who require medical, surgical, obstetrical, dental, and pediatric interventions. The results of a 1998 survey of program directors show that nurse anesthesia programs provide an average of 1595 hours of clinical experience for each student.

Accreditation of Educational Programs
The Council on Accreditation of Nurse Anesthesia Educational Programs is recognized by the US. Secretary of Education and the Commission on Higher Education Accreditation as the sole accrediting authority for nurse anesthesia programs. This council provides for systematic self-study and on-site evaluation of all nurse anesthesia educational programs. The Council on Accreditation publishes a list of accredited nurse anesthesia educational programs annually.

Certification of Nurse Anesthetists
The Council on Certification of Nurse Anesthetists (CCNA) is the certifying body that administers the national certification examination. Each graduate of a nurse anesthesia program must pass the national certification examination before he or she can be certified as a CRNA.

Recertification of Nurse Anesthetists
Recertification is required of CRNAs on a biennial basis. The recertification program is administered by the Council on Recertification of Nurse Anesthetists. This council reviews CRNA qualifications regarding (1) current licensure as a registered nurse, (2) continuing education (40 CE credits), (3) certification that he or she has been substantially engaged in the practice of anesthesia during the two year period, and (4) verification of the absence of mental, physical or other problems that could interfere with the practice of anesthesia.

Clinical Practice
CRNAs practice according to their expertise, state statutes or regulations, and institutional policy.

CRNAs administer anesthesia and anesthesia-related care in four general categories: (1) pre-anesthetic preparation and evaluation; (2) anesthesia induction, maintenance and emergence; (3) post-anesthesia care; and (4) perianesthetic and clinical support functions. The CRNA scope of practice includes, but is not limited to, the following:

(a) Performing and documenting a pre-anesthetic assessment and evaluation of the patient, including requesting consultations and diagnostic studies; selecting, obtaining, ordering, or administering pre-anesthetic medications and fluids; and obtaining informed consent for anesthesia.

(b) Developing and implementing an anesthetic plan.

(c) Selecting and initiating the planned anesthetic technique which may include: general, regional, and local anesthesia and intravenous sedation.

(d) Selecting, obtaining, or administering the anesthetics, adjuvant drugs, accessory drugs, and fluids necessary to manage the anesthetic, to maintain the patient's physiologic homeostasis, and to correct abnormal responses to the anesthesia or surgery.

(e) Selecting, applying, or inserting appropriate non-invasive and invasive monitoring modalities for collecting and interpreting patient physiological data.

(f) Managing a patient's airway and pulmonary status using endotracheal intubation, mechanical ventilation, pharmacological support, respiratory therapy, or extubation.

(g) Managing emergence and recovery from anesthesia by selecting, obtaining, ordering, or administering medications, fluids, or ventilatory support in order to maintain homeostasis, to provide relief from pain and anesthesia side effects, or to prevent or manage complications.

(h) Releasing or discharging patients from a post-anesthesia care area, and providing post-anesthesia follow-up evaluation and care related to anesthesia side effects or complications.

(i) Ordering, initiating or modifying pain relief therapy, through the utilization of drugs, regional anesthetic techniques, or other accepted pain relief modalities, including labor epidural analgesia.

(j) Responding to emergency situations by providing airway management, administration of emergency fluids or drugs, or using basic or advanced cardiac life support techniques.

(k) Additional nurse anesthesia responsibilities which are within the expertise of the individual CRNA.

The functions listed above are a summary of CRNA practice and are not intended to be all-inclusive. A more specific list of CRNA functions and practice parameters is detailed in the AANA Scope and Standards for Nurse Anesthesia Practice.

Clinical Support Services Provided Outside of Operating Room
CRNAs also provide clinical support services outside of the operating room. Anesthesia and anesthesia- related services are expanding to other areas, such as MRI units, cardiac catheterization labs and lithotripsy units. Upon request or referral these services include providing consultation and implementation of respiratory and ventilatory care, identifying and managing emergency situations, including initiating or participating in cardiopulmonary resuscitation that involves airway maintenance, ventilation, tracheal intubation, pharmacologic, cardiopulmonary support, and management of blood, fluid, electrolyte and acid-base balance.

Administrative and Other Professional Roles
Many CRNAs perform administrative functions for departments of anesthesia. The services provided by these department directors and managers are extremely important to the overall functioning of an anesthesia department and directly affect the efficiency and quality of service provided. These functions include personnel and resource management, financial management, quality assurance, risk management and continuing education.

CRNAs serve on a variety of institutional committees and participate as instructors in staff development and continuing education programs for both professional and non-professional staff members.

CRNAs hold staff and committee appointments with state and federal governmental agencies such as state boards of nursing and the U.S. Food and Drug Administration. CRNAs are also actively involved in professional and standard-setting organizations such as the National Fire Protection Association and the American Society for Testing and Materials.

Research
Nurse anesthetists have been involved as investigators, collaborators, consultants, assistants, interpreters and users of research findings since the turn of the century. Movement of nurse anesthesia educational programs into graduate educational frameworks has allowed students to graduate with basic skills for undertaking research. In addition, there is a growing number of CRNA faculty, credentialed at the graduate level, who regularly sponsor and consult in research endeavors and act as project directors or principal investigator for funded research in university settings. The AANA Foundation as a non-profit organization, promotes and facilitates research. The foundation established the Doctoral Mentorship Program to encourage seasoned researchers and novice researchers to share ideas and help each other. The group includes CRNAs with doctoral degrees as well those in doctoral programs.

At the AANA Annual Meeting, educational sessions are conducted in research methodology and grantsmanship. To respond to the current health care environment, the AANA has focused on quality and outcome-based research. The AANA, in cooperation with the AANA Foundation, provide venues for communicating research findings.

Additionally, CRNAs have presented their research at a variety of national and international meetings, including those sponsored by nurses, physicians, physiologists and pharmacologists. Research by CRNAs has been funded by private and governmental grants, as well as from the AANA Education and Research Foundation.

The AANA's research component has grown and is supported by the AANA Foundation. The AANA Foundation approves and funds small grants for CRNAs and nurse anesthesia students. In 1998,the Research Scholar award was the first large grant awarding up to $25,000. The award was initiated to encourage CRNAs to conduct research of greater magnitude.

Publications
CRNAs have authored numerous books, chapters in books, monographs and articles on clinical, educational and research subjects in a variety of refereed professional publications such as the AANA Journal, CRNA: The Clinical Forum for Nurse Anesthetists, Nurse Anesthesia, Anesthesiology Anesthesia and Analgesia, Journal of the American Society of Regional Anesthesia, Journal of the American Medical Association, Nursing Research and Hospitals.

Subspecialization
Some CRNAs have chosen to specialize in pediatric, obstetric, cardiovascular, plastic, dental or neurosurgical anesthesia. Others also hold credentials in fields such as critical care nursing and respiratory care. In addition to their membership in the AANA, many CRNAs also belong to in a variety of anesthesia and subspecialty organizations, including the following:

International Anesthesia Research Society
American Society of Regional Anesthesia
American Association of Critical Care Nurses
American Society of Perianesthesia Nurses
Association of PeriOperative Room Nurses
American Association of Respiratory Care
American Pain Society
Society of Office Based Anesthesia
Society for Obstetrical Anesthesia Perinatology
Society for Ambulatory Anesthesia
 
No Significant Differences in Anesthesia Outcome by Provider

Synopsis of Available Published Information Comparing CRNA and Anesthesiologist Patient Anesthesia Outcomes

Patients and healthcare institutions have an interest in information concerning the quality of care given by healthcare providers.

Nurse anesthetists have been providing quality anesthesia care in the United States for more than 100 years. In administering more than 65 percent of the anesthetics given annually, CRNAs have compiled an enviable safety record. No studies to date that have addressed anesthesia care outcomes have demonstrated that there is a difference in patient outcomes based on the type of provider.

1. In a study mandated by the U.S. Congress and performed by the National Academy of Sciences, National Research Council, the report to Congress states: "There was no association of complications of anesthesia with the qualifications of the anesthetist or with the type of anesthesia." (House Committee Print No. 36, Health Care For American Veterans, page 156, dated June 7,1977.)

2. A study concerning anesthetic-related deaths from 1969-1976 by Albert Bechtoldt, Jr. and the Anesthesia Study Committee, published in the North Carolina Medical Journal in April 1981, stated on page 257 that: "Therefore, when we calculated the incidence of anesthetic-related deaths for each group which administered the anesthetic (Figure 2), we found that the incidence among the three major groups (the CRNA, the anesthesiologist and the combination of CRNA and anesthesiologist) to be rather similar. Although the CRNA working alone accounted for about half of the anesthetic-related deaths, the CRNA working alone also accounted for about half of the anesthetics administered."

3. The Stanford Center for Health Care Research conducted a 17-hospital intensive study of institutional differences. A report of the study stated that: "Thus, using conservative statistical methods, we concluded that there were no significant differences in outcomes between the two groups of hospitals defined by type of anesthesia provider." See Forrest WH Jr. "Outcome-The Effect of the Provider," at page 137 in Hirsh RA, et al (eds): Health Care Delivery in Anesthesia. 1980. Philadelphia: George F. Stickley Company.

4. A 1994 legislatively mandated study by the Minnesota Department of Health looked at the provision of anesthesia services by anesthesiologists and certified nurse anesthetists. The resulting assessment of the existing studies determined that there are no studies, either national or Minnesota- specific, that conclusively show a difference in patient outcomes based on type of anesthesia provider.

5. The Center for Health Economics Research (CHER) completed a report in January 1988 for the Health Care Financing Administration (HCFA). The purpose of the report was to assist HCFA in the development of a fee schedule for CRNA direct Medicare reimbursement, effective January 1, 1989. CHER is an independent Boston-area based research organization that analyzes and evaluates federal health programs. As part of the report, CHER conducted a review of the literature concerning anesthesia quality. CHER addressed the question of whether the quality of anesthesia care varies by the type of anesthesia provider. As part of its literature review, CHER reviewed three studies which have explicitly examined anesthesia outcomes by provider type. The CHER researchers concluded that "none of the studies detected significant differences in anesthesia outcomes among nurse anesthetists versus anesthesiologists." The CHER researchers stated that anesthesia outcomes between CRNAs and anesthesiologists "have not been shown to differ."

The U.S. House of Representatives Committee on Armed Services Report on H.R.1748, the Department of Defense Authorization Act for Fiscal Year 1988-89, commented on a proposed change in the supervision of nurse anesthetists in the military services that would require anesthesiologist supervision. The committee stated that: "From the quality of care standpoint, the committee is not aware of any data that suggests that nurse anesthetists need a higher level of supervision than they currently have. If such data exists, the committee would be very interested to review it."

At pages 208 to 209, the report stated that: "The committee understands that the current practice in the civilian, as well as military, medical care systems is that a nurse anesthetist must be supervised by a physician. Under the change proposed within the military, a nurse anesthetist would be required to be supervised by an anesthesiologist.

"The committee is extremely skeptical that such a policy change makes sense from a patient care, quality of care or medical readiness standpoint. In terms of patient care, the requirement that an anesthesiologist supervise every anesthetist would mean that many anesthesiologists would be forced to provide less patient care. Some small hospitals that currently have only one nurse anesthetist and no anesthesiologist would lose their anesthesia capability altogether under this proposal."

In concluding the discussion of this subject, the House committee said that the adoption of a change in policy that would require anesthesiologist supervision of nurse anesthetists must be supported by compelling reasons, with full explanation and supporting data.

The practice of anesthesia has become safer in recent years due to improvements in pharmacological agents and the introduction of sophisticated technology. Recent studies have shown a dramatic reduction in anesthesia mortality rate to approximately 1 per 250,000 anesthetics.

In 1990, the Center for Disease Control (CDC) intended to conduct a research study on morbidity and mortality in anesthesia. Following a review of the anesthesia data, the CDC concluded that morbidity and mortality in anesthesia was too low to warrant the study.

In a 1988 book, Mark Wood of the St. Paul Fire and Marine Insurance Company summarized a St. Paul study of its anesthesia-related claims. St. Paul studied the leading medical liability allegations that St. Paul-insured anesthesiologists and CRNAs reported between 1981 and 1985. The data consisted of all claims, including pending and closed claims. St. Paul concluded that "nurse anesthetist loss experience is very similar to that of anesthesiologists..." See Wood, MD, "Monitoring Equipment and Loss Reduction: An Insurer's View," in Gravenstein JS, Holzer JF (eds): Safety and Cost Contained in Anesthesia. 1988. Stoneham, Mass.: Butterworth Publishers.

From 1988 to 1995, St. Paul has returned nearly $24,000,000 in premiums to it's insured CRNAs because the loss experience was substantially better than St. Paul originally predicted. Further, St. Paul stated in a July 1995 publication: The St. Paul Medical Services Nurse Anesthetist Update, that "nurse anesthetists insured by St. Paul will experience an average countrywide 7 percent decrease in their medical professional liability insurance rates in 1995.

AANA General Counsel Gene A. Blumenreich of Nutter, McClennen and Fish, LLP, Boston, Massachusetts has concluded that while the fact that there is no difference regarding the quality of care rendered by anesthesiologists and CRNAs "may be surprising to the less knowledgeable, an understanding of the nature of anesthesia would lead one to expect this. The vast majority of anesthesia-related accidents have nothing to do with the level of education of the provider." Blumenreich GA, Wolf BL. 1986. "Restrictions on CRNAs imposed by physician-controlled insurance companies." AANA Journal 54:6:538-539.

The most common anesthesia accidents are lack of oxygen supplied to the patient (hypoxia), intubation into the esophagus rather than the trachea and disconnection of oxygen supply to the patient. All of these accidents result from lack of attention to monitoring the patient, not lack of education. In fact, the Harvard Medical School standards in anesthesia are directed toward monitoring, which reiterates the basic point: Most anesthesia incidents relate to lack of attention to monitoring the patient, not lack of education.

As Mr. Blumenreich has stated: "Anesthesia seems to be an area where, beyond a certain level, outcome is only minimally affected by medical knowledge but is greatly affected by factors such as attention, concentration, organization and the ability to function as part of a team; factors toward which all professions strive but which no profession may claim a monopoly." Id.

CRNAs offer a cost-effective alternative to all-physician care in the field of anesthesia. Anesthesia is an appropriate specialty for either nurses or physicians. The evidence to date is compelling and comprehensive that CRNAs provide safe, quality anesthesia care. Patient outcome is similar regardless of whether the anesthesia provider is a CRNA or an anesthesiologist.
 
Quality of Care in Anesthesia

Introduction
Nurse anesthetists have been providing quality anesthesia care in the United States for more than 100 years. In administering more than 65 percent of the anesthetics given annually, CRNAs have compiled an enviable safety record. No studies to date that have addressed anesthesia care outcomes have found that there is a significant difference in patient outcomes based on whether the anesthesia provider is a CRNA or an anesthesiologist.

The practice of anesthesia has become safer in recent years due to improvements in pharmacological agents and the introduction of sophisticated technology. Recent studies have shown a dramatic reduction in anesthesia mortality rate to approximately one per 250,000 anesthetics.

That there is no significant difference regarding the quality of care rendered by anesthesiologists and CRNAs "may be surprising to the less knowledgeable, an understanding of the nature of anesthesia would lead one to expect this. The vast majority of anesthesia-related accidents have nothing to do with the level of education of the provider." [Blumenreich GA, Wolf BL. "Restrictions on CRNAs imposed by physician-controlled insurance companies." AANA Journal. 1986;54:6:538-539, at page 539.]

The most common anesthesia accidents are lack of oxygen supplied to the patient (hypoxia), intubation into the esophagus rather than the trachea, and disconnection of oxygen supply to the patient. All of these accidents result from lack of attention to monitoring the patient, not lack of education. In fact, the Harvard Medical School standards in anesthesia are directed toward monitoring, which reiterates the basic point - most anesthesia incidents relate to lack of attention to monitoring the patient, not lack of education.

As Blumenreich has stated:

Anesthesia seems to be an area where, beyond a certain level, outcome is only minimally affected by medical knowledge but is greatly affected by factors such as attention, concentration, organization and the ability to function as part of a team; factors towards which all professions strive but which no profession may claim a monopoly. See id. at page 539

Section One

Summary of Pertinent Quality of Care Studies and Data

1. Bechtoldt Study
[Bechtoldt, Jr, AA. "Committee On Anesthesia Study. Anesthetic- Related Deaths: 1969-1976." North Carolina Medical Journal. 1981;42:253-259.]

A. Background
A 10-member Anesthesia Study Committee (ASC) of the North Carolina Medical Society reviewed approximately 900 perioperative deaths in that state over the eight-year period from 1969 to 1976. The ASC determined that 90 perioperative deaths were, to a certain extent, related to the administration of an anesthetic. The ASC did not study types of anesthesia-related outcomes other than death. Based on an ASC survey of hospitals, the ASC estimated that more than two million anesthetics were administered in North Carolina from 1969 to 1976.

The ASC defined "anesthetic-related" deaths as those in which the ASC determined that anesthesia was found to be a) the sole cause of death or b) the major contributing factor.

In categorizing cases, the ASC used information from death certificates and questionnaires completed by anesthesia providers of record. Based on that data, the ASC estimated that there had been one anesthetic-related death per 24,000 anesthetics administered.

The ASC used six different criteria to review the cases, including the following:

type of anesthetic involved
location where anesthesia was administered within the facility
type of practitioner(s) involved in anesthesia administration
surgical procedure or operation
patient risk classification
B. Comparison of Outcome According to Provider Type
The ASC classified those who had administered anesthesia as follows:

Certified Registered Nurse Anesthetist (CRNA) working alone
anesthesiologist working alone
CRNA and anesthesiologist working together
surgeon or dentist
unknown (in some of the cases, the type of practitioner administering the anesthetic was not identifiable based upon the information available to the ASC)
Bechtoldt reported that the ASC:

... found that the incidence among the three major groups (the CRNA, the anesthesiologist, and the combination of CRNA and anesthesiologist) to be rather similar. Although the CRNA working alone accounted for about half of the anesthetic-related deaths, the CRNA working alone also accounted for about half of the anesthetics administered. [page 257] [emphasis added]

Bechtoldt stated that the ASC's study included patients representing all risk categories. The study did not, however, address whether particular types of anesthesia providers (i.e., anesthesiologists or CRNAs) tended to encounter patients having particular risk factors. Because CRNAs working alone provided approximately half of the nearly two million anesthetics administered in the state during the period of the study, it is reasonable to believe CRNAs provided care to patients covering the full spectrum of physical status and anesthetic risk.

2. Forrest Study
[Forrest, WH. "Outcome - The Effect of the Provider." In: Hirsh, R, Forrest, WH, et al., eds. Health Care Delivery in Anesthesia. Philadelphia: George F. Stickley Company. Chapter 15.1980:137-142.]

Forrest reviewed data that had been collected as part of an intensive hospital study of institutional differences that the Stanford Center for Health Care Research conducted. Forrest analyzed mortality and severe morbidity outcome data from 16 randomly selected hospitals, controlling for case-mix variations. The data concerned 8,593 patients undergoing 15 surgical procedures over a 10-month period (May 1973 through February 1974). Using that data, Forrest compared outcomes based upon type of anesthesia provider.

For study purposes, the hospitals were classified as having either:

1. primarily physician (anesthesiologist) providers (9 hospitals), or
2. primarily nurse anesthetist providers (7 hospitals).

Each of the 8,593 patients were "weighted" to reflect the progression or stage of disease at the time of surgery, and "the probability of developing postoperative morbidity and mortality, given the stage of the patient's disease." Forrest initially compared actual patient outcome to the outcome that would have been predicted based upon the patient's preoperative health status and the surgery performed. Compared with outcomes predicted, the actual results showed no significant difference in outcome between facilities having primarily nurse anesthetists or those having primarily physician anesthesiologists.

Forrest then looked at the data using three scales that differed based on definitions of "morbidity" applied to each scale. Slight differences between the two groups (i.e., primarily nurse anesthetist, or primarily anesthesiologist) were found, but the favored group varied according to the analysis criteria employed. That is, depending on criteria, sometimes the anesthesiologist-dominated group showed better outcomes, and sometimes the nurse anesthetist-dominated group fared better. After applying statistical tests to the results, Forrest stated:

Thus, using conservative statistical methods, we concluded that there were no significant differences in outcomes between the two groups of hospitals defined by type of anesthesia provider. Different methods of defining outcome changed the direction of differences for two weighted morbidity measures. [page 141] [emphasis added]

The Forrest study was presented at a 1977 symposium sponsored by the Association of University Anesthetists; the symposium dealt with the broader subject of "Epidemiology and Demography of Anesthesia." Official comments concluding this anesthesiologist-dominated proceeding (Chapter 25 of Health Care Delivery in Anesthesia, cited above) showed that the findings of Dr. Forrest, as well as others researching provider aspects of outcomes, caught some of the symposium participants off guard. As one commenter stated:

It was surprising that the stage of training of the anesthesiologist or administration of an anesthetic by a nurse anesthetist or anesthesiologist seemed to affect risk very little.... [page 220]

Still another physician commenter, who was chair of a university-based anesthesia department, articulated a reaction possibly shared by many of his colleagues in academia:

Dr. Forrest's very carefully done study showed no difference in outcome whether the provider was a nurse anesthetist or an anesthesiologist.... If we had to accept the data that there are no differences in outcome between anesthetics administered by anesthesiologists compared to nurse anesthetists, the consequences would be truly extraordinary. It would mean that we would have to question our very careers; we would have to question the value of anesthesia residency training programs; we would have to question organization in hospitals; we would have to question and reexamine projections for manpower needs in the future; we would have to question medical economics as they are projected right now. With some of the data presented to us [during the full symposium] we were very comfortable because they matched expectations... Now in the study comparing nurse anesthetists and anesthesiologists, we do not have this comfort. [pages 223-224]

3. Minnesota Department of Health Study
In 1994, the Minnesota Department of Health (DOH), as mandated by the state Legislature, studied the provision of anesthesia services by CRNAs and anesthesiologists. The department reached four conclusions, including the following:

There are no studies, either national in scope or Minnesota- specific, which conclusively show a difference in patient outcomes based on type of anesthesia provider. [page 23, DOH study.] [emphasis added]

4. Centers for Disease Control
In 1990, the federal Centers for Disease Control (CDC) considered undertaking a multimillion-dollar study regarding anesthesia outcomes. Following a review of anesthesia data from a pilot study issued by the CDC and the Battelle Human Affairs Research Centers, however, the CDC concluded that morbidity and mortality in anesthesia was too low to warrant a broader study. The pilot study, published on December 1, 1988, was entitled, "Investigation Of Mortality and Severe Morbidity As- sociated With Anesthesia: Pilot Study." The pilot study stated that:

To obtain regional estimates of rates of mortality and severe morbidity totally associated with anesthesia with a precision of about 35% a nationwide study consisting of 290 hospitals should be selected. This size study would cost approximately 15 million dollars spread over a 5-year period.

5. National Academy of Sciences Study
This study was mandated by the U.S. Congress and performed by the National Academy of Sciences, National Research Council. The report to Congress stated: 'There was no association of complications of anesthesia with the qualifications of the anesthetist or with the type of anesthesia." [House Committee Print No. 36, Health Care for American Veterans, page 156, dated June 7,1977.]

6. St. Paul Data
The St. Paul Fire and Marine Insurance Company malpractice insurance premium rate for claims-made coverage for self-employed CRNAs decreased nationally a total of 52 percent from 1988 through 1998. The premium drop is detailed in the Appendix entitled, "Nurse Anesthetist Professional Liability Premiums." St. Paul is the country's largest provider of liability insurance for health care professionals, and insures both CRNAs and anesthesiologists.

From 1988 to 1996, St. Paul returned nearly $26,000,000 in premiums to its insured CRNAs because the loss experience was substantially better than St. Paul originally predicted.

The decline in CRNA malpractice insurance premium rates demonstrates the superb anesthesia care that CRNAs provide. The rate drop is particularly impressive considering inflation, an increasingly combative legal system, and generally higher jury awards.

In a 1988 book, Mark Wood of St. Paul Fire and Marine Insurance Company summarized a St. Paul study of its anesthesia-related claims. St. Paul studied the leading medical liability allegations that St. Paul-insured anesthesiologists and CRNAs reported between 1981 and 1985. The data consisted of all claims, including pending and closed claims. St. Paul concluded that "[n]urse anesthetist loss experience is very similar to that of anesthesiologists..." [Wood, MD, "Monitoring Equipment and Loss Reduction: An Insurer's View," in Gravenstein JS, Holzer JF (eds): Safety and Cost Contained in Anesthesia. 1988. Stoneham, Mass.: Butterworth Publishers.]

Clearly, CRNAs have enjoyed a tremendous decline in professional liability premiums over the past decade. The Appendix details premium information from St. Paul for CRNAS, both on a state-by-state basis, and nationally
Quality of Care in Anesthesia

Section Two

Anesthesiologist Distortions Concerning Quality of Care
The following section discusses the articles (by Abenstein and Warner; Silber, et al.; and Wiklund and Rosenbaum) that anesthesiologists have primarily cited to support their view that CRNAs should be anesthesiologist supervised, and that utilization of anesthesiologists improves anesthesia outcomes. As the following will demonstrate, however, none of the articles cites any credible scientific evidence that validates the anesthesiologists' position. In fact, two of the three articles do not even discuss the role of CRNAs in anesthesia care.

1. Abenstein and Warner Article in Anesthesia & Analgesia [Abenstein, JP, Warner, MA. "Anesthesia providers, patient out- comes and costs." Anesthesia & Analgesia. 1996;82:1273-1283.1

A. Abenstein and Warner Distortions Concerning Minnesota Department of Health Study
The Minnesota Department of Health (DOH) study discussed earlier led to development of the Abenstein and Warner article. In its 1994 study of the provision of anesthesia services by CRNAs and anesthesiologists, the DOH reached four "key findings,"1 including the following:

There are no studies, either national in scope or Minnesota-specific, which conclusively show a difference in patient outcomes based on type of anesthesia provider. [page 23, DOH study] [emphasis added]

The Minnesota Society of Anesthesiologists (MSA) had urged the DOH to reach different conclusions, and the department refused to do so. Disappointed that their views about quality weren't reflected in the department's report, anesthesiologists decided to seek a different forum to air their opinions. Two Minnesota anesthesiologists - doctors Abenstein and Warner - essentially repackaged the MSA's report that the MSA had submitted to the DOH, and published it as an article in June 1996 in Anesthesia and Analgesia. Abenstein and Warner acknowledge in their article that it "is an abridged version of a document submitted by the Minnesota Society of Anesthesiologists to the Minnesota Commissioner of Health." [page 1273]

The Abenstein and Warner article purported to analyze quality of care in anesthesia, quoted the Minnesota Department of Health report at length at the end of the article, but failed to mention the key conclusion about quality quoted above. It is clear that Abenstein and Warner failed to mention the conclusion because it did not fit their thesis that CRNAs should be anesthesiologist supervised.

As Christine Zambricki states in the enclosed article from the October 1996 AANA Joumal:

We are curious as to how the authors' [Abenstein and Warner] omission of three of the [Minnesota DOH'S] four concluding findings could be overlooked in Anesthesia and Analgesia's extensive peer and editorial review. This is especially surprising because the finding that directly contradicts Abenstein and Warner's principal thesis was considered crucial enough to the report to be restated in the report's executive summary. If, as the Minnesota Department of Health's report contends, there are no studies that 'conclusively show a difference in patient outcomes based on type of anesthesia provider,' it becomes difficult, if not impossible, to support the authors' thesis that an increase in the number of practicing anesthesiologists is the primary reason for the decrease in anesthesia-related mortality.

[Zambricki, CS. "'Anesthesia providers, patient outcomes, and costs': the AANA responds to the Abenstein and Warner article in the June 1996 Anesthesia and Analgesia." AANA Journal, 1996;64:413-416, at page 415.]

The Abenstein and Warner article is a partisan advocacy piece - it is not a credible scientific evaluation. Remarkably, despite his subsequent decision to publish the Abenstein and Warner article, the editor of Anesthesia and Analgesia (Dr. Ronald Miller), stated that:

There were many reasons not to publish this paper. First, as recognized by Abenstein and Warner,'[it] lacks the scientific credibility of a review or original article and is related to policy making more than science'...Abenstein and Warner often are not only subjective, but clearly biased toward one method of anesthesia care delivery... [Miller, Ronald D., "Perspective from the Editor-in-Chief: Anesthesia Providers, Patient Outcomes, and Costs." Anesthesia and Analgesia. June 1996, 82:1117-18.]

B. Abenstein and Warner Distortions Relating to Increased Number of Anesthesiologists and Anesthesia Safety

Abenstein and Warner conclude that improved patient outcomes associated with the administration of anesthetic agents have resulted almost exclusively from the growth of the number of practicing anesthesiologists. In contrast, as noted above, the Minnesota Department of Health concluded that studies to date do not show a difference in patient outcome based on whether the anesthesia provider is an anesthesiologist or CRNA, rejecting the position argued by Abenstein and Warner.

Gross variations between observed reductions in anesthesia-related mortality compiled by Abenstein and Warner and the growth in membership reported by the American Society of Anesthesiologists suggests that there is little, if any, correlation between the reduction in mortality and an increase in anesthesiologists. Increases in the numbers of practicing nurse anesthetists show the same long-term growth as anesthesiologists, and variations in the rate of growth of CRNAs seem to coincide with the variations in the decline of mortality compiled by Abenstein and Warner.

The exponential decline in anesthesia-related mortality has resulted from the almost complete elimination of administrators lacking anesthesia education; improvements in technology and anesthetic agents; a marked increase in the proportion of patients who received anesthesia care from highly educated anesthesia specialists, including anesthesiologists and CRNAs; and an increased understanding of the causes of adverse events associated with anesthesia.

In two different letters to the editor of Anesthesia & Analgesia, physicians elaborated on the flaws in Abenstein and Warner's analysis:

1 ."It is interesting that there exist no data within the last 20 years concerning patient outcome as a function of anesthesia provider. Much has changed in anesthetic practice in 20 years, not only from the standpoint of medical and technical factors, but also in terms of the distribution of providers, the types of patients and surgeries encountered by these providers, and the organizational nature of these practices.... In summary, although the data, information, and analyses provided by the authors are interesting and provocative, I strongly disagree with their nearly unqualified statement that 'the anesthesia care team and hybrid practices appear to be the safest methods of delivering anesthesia care. This safety may be due, in part, to the rapid availability of physicians, especially during medical crises.' The question of how best to organize anesthesia care (or any other type of medical care) for achieving maximum patient safety has not yet been thoroughly examined. It is inappropriate to make claims such as those made by the authors based on such a paucity of data and analysis." [David M. Gaba, MD, Department of Anesthesia, Stanford University School of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, California; Anesthesia & Analgesia. December 1996, 82:1347-1348, Letters to the Editor.]

2. "...I question the validity of the conclusion reached by the authors [Abenstein and Warner] regarding the anesthesia care team in which they state, 'When the data are critically examined, the evidence is very supportive that the anesthesiologist-led anesthesia care team is the safest and most cost effective method of delivering anesthesia care. At this time, public policy decisions should encourage the development of anesthesia care teams where none exist, particularly in the rural areas, and assure the continued utilization of this patient care model'....Unchallenged acceptance of the conclusion that evidence supports a specific method of anesthesia care delivery to be the 'safest and most cost effective' is misleading to patients, colleagues, and those responsible for shaping health care delivery policy... the participation of Certified Registered Nurse Anesthetists (CRNAs) in delivery of anesthesia care would have ceased many years ago if there was evidence that this participation resulted in a less favorable outcome compared with anesthesia personally administered by an anesthesiologist." [Robert K. Stoelting, MD, Department of Anesthesia, Indiana University School of Medicine, Indianapolis; Anesthesia & Analgesia. December 1996, 82:1347, Letters to the Editor.]

C. Abenstein and Warner Distortions Relating to the Bechtoldt and Forrest Studies

The report submitted to the Minnesota Department of Health by the Minnesota Society of Anesthesiologists, and the Abenstein and Warner article, rewrote the findings of the Bechtoldt and Forrest studies that we summarized previously. Abenstein and Warner claim that the studies show that there were differences in the outcomes of care based on type of provider, notwithstanding that the actual researchers came to the opposite conclusion.

The Minnesota Department of Health report, in addressing the Bechtoldt study, stated:

Observed differences [in the incidence of anesthetic-related deaths] suggest that anesthesiologists and the CRNA-anesthesiologist care team were somewhat associated with lower rates of anesthesia-related deaths than CRNA's [sic] working alone. However, given the absence of controls, the findings cannot be used to determine (1) whether the differences are greater than would be expected by chance, or (2) the extent that the type of anesthesia provider is responsible for the differences versus other factors. The author concluded that the incidence of patient death among these groups is 'rather similar.' [page 12, Minnesota DOH study]

Concerning the Forrest study, the Minnesota Department of Health stated:

Outcomes considered were deaths, complications, and intermediate outcomes. Ratios of the actual number of adverse outcomes (or deaths, morbidity, or weighted outcome scales) to the number predicted from selected patient and hospital characteristics (i.e., indirectly standardized outcomes ratios) for the two groups were compared and tested. The study concluded that, although there were some unadjusted outcome differences between the two groups, after controlling for patient and hospitals characteristics, there were no statistically significant differences in outcomes between the two groups of hospitals defined on the basis of primary type of anesthesia provider. [page 11, Minnesota DOH study]

The enclosed December 1996 AANA Journal article by Denise Martin-Sheridan and Paul Wing, as well as the Zambricki article cited earlier, details the Abenstein and Warner article's numerous distortions and errors. Martin-Sheridan and Wing conclude that:

In general, the authors [Abenstein and Warner] reconfigure statistics and findings in the literature concerning outcomes of anesthesia care based on provider. If the best available research studies did not support their position, we feel it was inappropriate and misleading to reconfigure data upon which recommendations for policy decisions were made.

[Martin-Sheridan, D, Wing, P "Anesthesia providers, patient outcomes, and costs: a critique." AANA Journal 1996; 64(6):528- 534, at page 533.]

2. Silber Study in Medical Care
[Silber, JH, Williams, SV, Krakauer, H, Schwartz, JS. "Hospital and Patient Characteristics Associated With Death After Surgery. A Study of Adverse Occurrence and Failure to Res- cue." Medical Care. 1992;30:615.]

The Silber study examined the death rate, adverse occurrence rate, and failure rate of 5,972 Medicare patients undergoing two fairly low-risk procedures -- elective cholecystectomy and transurethral prostatecto my. The study did not discuss any anesthesia provider except physician anesthesiologists; the study did not even mention CRNAs. The study, therefore, had nothing to do with CRNAs and did not compare the outcomes of care of nurse anesthetists to those of anesthesiologists. The study did not address any aspect of CRNA practice; it certainly did not explore the issue of whether CRNAs should be physician supervised.

The Silber study was a pilot study, i.e., a study to demonstrate the feasibility of performing a more definitive study concerning patients developing medical complications following surgery. It would be inappropriate to formulate public policy based on the Silber study; the study does not address CRNAs, and cannot be considered conclusive even about the issues that it does address. The Silber study states, at page 625:

This pilot project examined ideas that, to our knowledge, have not been examined previously, and more work is needed before the full significance of the results can be determined. It is especially appropriate, therefore, that the limitations of the project be recognized.

At most, the study's conclusions support the proposition that certain facilities would benefit from having a board-certified anesthesiologist in the Intensive Care Unit. This might result in the "rescue" of some patients who have undergone elective cholecystectomies and transurethral prostatectomies and developed life-threatening postoperative complications. The Silber study's conclusions have nothing to do with nurse anesthetists or the nature of who may supervise, direct, or collaborate with nurse anesthetists. At most, the study concluded that anesthesiologists may play a clinically valuable role in caring for postoperative complications. The study, however, did not involve examination of the outcomes of anesthesia in the operating room.

In his analysis of the Silber study, Dr. Michael Pine (physician and expert in quality and health care) stated that:

Thus, the presence of board-certified anesthesiologists does not appear to lower the rate of complications, either alone or in combination with other factors such as high technology. It is not anesthesia care but the failure to rescue patients once complications occur which contributes to the death rate. On the other hand, unmeasured factors such as a higher percentage of other board-certified physicians in the hospital, also may account for the better outcomes. The conclusion to be drawn from this study is that, although the presence of board-certified anesthesiologists may not make a difference in the operating room, it may make a difference in the failure to rescue patients from death or adverse occurrences after postoperative complications have arisen. This conclusion is in keeping with the expanded role that anesthesiologists have identified for themselves in post-operative care....

Dr. Pine went on to conclude, in pertinent part, regarding the Silber study that:

"1. This study encompassed the entire period of operative and postoperative care and was not specific to anesthesia staffing.

2. The rate of deaths possibly attributable to anesthesia care is a negligible fraction of the death rate found in this study.

3. The factors that significantly affect mortality and are most amenable to clinical interventions arise during postoperative management, not during the administration of anesthesia.

4. The type of anesthesia provider does not appear to be a significant factor in the occurrence of potentially lethal complications. If anything, this study suggests that surgical skill is more important.

5. The presence of board-certified specialists does appear to make an important difference in post-surgical care."

Pennsylvania anesthesiologists have unsuccessfully attempted to use the Silber study as a justification for a restrictive regulation they have urged the state's board of medicine to adopt. While the board proposed the regulation, it has not adopted it. Reportedly, the board decided at a March 1998 meeting to withdraw the proposal. The proposed regulation would have required physicians who delegate duties to CRNAs to have qualifications that only anesthesiologists typically possess. The practical effect would have been to require CRNAs to be anesthesiologist supervised in every practice setting.

Significantly, the Independent Regulatory Review Commission (IRRC), a Pennsylvania oversight commission that reviews health care proposals, carefully evaluated the Silber study, and issued a report rejecting the study as any basis for requiring anesthesiologist supervision of CRNAs. The IRRC stated that:

Based on our review of the 1992 Medical Care article, we have concluded, as its authors clearly state, it is a preliminary study and that caution should be taken in making any definitive conclusions. More importantly, the authors did not consider the scenario of an operating physician delegating the administration of anesthesia to a CRNA, or what expertise the operating physician should have in order to safely delegate anesthesia to a CRNA. Therefore, we do not believe this study should be used as justification for the significant change in practice for the ad- ministration of anesthesia.

The IRRC further stated that:

There have been two studies, both completed over 20 years ago, that compared the outcomes of anesthesia services provided by a nurse anesthetist and an anesthesiologist. Neither of these studies concluded that there was any statistically significant difference in outcomes between the two providers. This conclusion was also reached by the Minnesota Department of Health, which recently completed a study on the provision of anesthesia services. In fact, most studies on anesthesia care have shown that adverse outcomes and deaths resulting from anesthesia has decreased significantly in the last several decades as [a] result of improved drugs and monitoring technology.

3. New England Journal of Medicine Articles (by Wiklund and Rosenbaum)
[Wiklund, RA, Rosenbaum, SH. "Medical Progress: Anesthesiology" (part one). New England Journal of Medicine. 1997;337(16):1132- 1 1 41. Wiklund, RA, Rosenbaum, SH. "Medical Progress: Anesthesiology" (part two). New England Journal of Medicine. 1997;337(17): 1215-1219.1

These articles attempt to summarize key developments in the broad field of anesthesiology during the past 30 years. The articles focus on "preparation of patients for surgery, recent developments in anesthetic agents and techniques, multimodal pain management, and postoperative complications related to anesthesia."

The articles, however, do not attempt to compare patient outcomes by type of anesthesia provider. In fact, the articles do not discuss the involvement or contributions of CRNAs. The articles, therefore, have no relevance to the issue of CRNA versus anesthesiologist quality, and certainly have no bearing on the question of whether CRNAs should be physician supervised.

The articles have some merit as an overview of anesthesiology developments during the past 30 years. For example, the authors discuss advances in applied research that have led to new technology, products, and techniques. In certain areas, however, the authors leave the path of an unbiased review of the specialty to make unsubstantiated or misleading comments about the unilateral contributions of anesthesiologists to the advancements achieved.

For example, part one of the article states in its opening paragraph that anesthesia-related deaths have decreased dramatically since the late 1960s, coinciding with a decision by the National Institutes of Health to "support training in clinical anesthesiology." While it makes logical sense that proper training should enhance outcomes in all disciplines, the reader is left to assume that it was this seminal event - physician training in anesthesiology - which has led directly to the decreased mortality rates mentioned.

In fact, many factors, some of which are discussed in the articles, have influenced the trend to improved anesthesia-related outcomes. The articles make little attempt to provide statistical support regarding the causes of outcome trends and do not compare outcomes based upon type of anesthesia provider, type of case, surgical setting, or patient physical status.

The authors make the blanket statement that:

Increasingly, anesthesiologists direct the preoperative assessment and preparation of patients for surgery with the aim of ensuring safe and efficient care while controlling costs by reducing unnecessary testing and preventable cancellations on the day of surgery. [page 1132]

While the value of preoperative patient assessment is indisputable, the authors reference only one article to substantiate their claim that anesthesiologist management of this process is particularly beneficial. In that case study [Fischer, SP "Development and Effectiveness of an Anesthesia Preoperative Evaluation Clinic in a Teaching Hospital." Anesthesiology. 1996;85(l):196-206], cost-savings are reported through the use of an organized preoperative assessment clinic staffed by anesthesiologists and nurse practitioners, a service not previously available at this large, university-based medical center. Consequently, both nurses and physicians contributed to the clinic's cost effectiveness. Any inferences to be drawn from the Fischer article are limited, because the article is based on a case study of a single anesthesia preoperative evaluation clinic. Moreover, the Fischer study did not compare CRNA preoperative evaluation effectiveness with that of anesthesiologists.

The Fischer article points out the benefits of developing protocols for reasonable preoperative testing and evaluation, but breaks no new ground in this area. If anything, the findings indicate that cost effective care in the preoperative period results from multidisciplinary guideline development and acceptance, as opposed to guidelines developed and managed solely by anesthesiologists.

Wiklund and Rosenbaum fail to support their premise that anesthesiologists, as a group, are "increasingly" staffing preoperative clinics and developing their own standardized protocols for assessing patients. In fact, their analysis of the Fischer article suggests there is a trend toward protocols developed by various specialties that can be utilized by all providers caring for the patient in the preoperative period.

Examples referenced in the article include guidelines jointly developed by the American College of Cardiology and the American Heart Association regarding the preoperative cardiovascular evaluation of patients undergoing noncardiac surgery. According to the authors, these guidelines have actually replaced those previously developed and standardized by anesthesiologists.

Further misleading editorial comments appear in part two of the article. Addressing the subject of new techniques of patient monitoring, the authors state:

Prompted by the Harvard Medical School report on standards of monitoring during anesthesia, the American Society of Anesthesiologists has become a leader in the adoption of standards of care and guidelines for practice. As a result, pulse oximetry and capnography (the analysis of carbon dioxide in exhaled air) are now used routinely to monitor general anesthesia in virtually all surgical patients in the United States. [page 1217]

Once again, the authors blend legitimate technological advancement with credit to a single professional group. In fact, the Harvard monitoring standards referenced here were first adopted and promoted by the American Association of Nurse Anesthetists. While it is true that the American Society of Anesthesiologists has since endorsed the standards as well, it is absurd to claim that oximetry and capnography have become anesthesia standards of care solely "as a result" of the ASA's endorsement.

Quality of Care in Anesthesia

Summary
This publication has demonstrated that CRNAs provide superb anesthesia care, and has refuted anesthesiologist contentions to the contrary. Anesthesia-related accidents are infrequent; those that do occur tend to result from lack of vigilance rather than the level of education of the provider. The federal Centers for Disease Control has considered conducting a large-scale study on anesthesia care, but decided such a study would not be worth the high cost such a study would entail. The reason is that the evidence is overwhelming that anesthesia care is very safe, regardless of whether the care is given by a CRNA or anesthesiologist. It is clear that studies to date demonstrate that there is no statistically significant difference between the anesthesia care provided by CRNAs working alone, CRNAs working with anesthesiologists, or anesthesiologists providing care alone. In addition, malpractice insurance premiums (as shown by St. Paul Fire and Marine Insurance Company statistics) for CRNAs have decreased significantly over the past 1 0 years, further demonstrating that CRNAs provide safe anesthesia care.
 
HHS Overturns Clinton Ruling..... :clap: :clap:

ASA NEWS RELEASE:
HHS Suspends Clinton Anesthesia Supervision Rule; Doctors Will Be There for Seniors-
The more than 40 million seniors on Medicare will continue to have a doctor involved in their anesthesia care for surgery, now that the Bush administration has suspended a rule change put through by the Clinton administration.

The American Society of Anesthesiologists (ASA) today congratulated President George W. Bush and Secretary of Health and Human Services (HHS) Tommy Thompson on the decision to retain the 35-year-old Medicare requirement that anesthesia nurses be supervised by a physician.

Just days before leaving office, President Bill Clinton had issued a new rule that would have allowed anesthesia nurses to administer anesthesia to Medicare and Medicaid patients without physicians being involved.

Now, HHS has made the determination that the rule will not go into effect as scheduled, and the department will soon introduce a proposal that addresses two new points:

A state Governor could apply to HHS for a waiver of the supervision rule, provided it is consistent with state law and following consultation with the state?s boards of medicine and nursing. The Governor would also have to determine that removal of the supervision requirement is in the best interest of the citizens of that state.

A prospective patient outcomes study, as long advocated by ASA, would be undertaken to compare different anesthesia practices by state.
According to ASA president Neil Swissman, M.D., "This is a great day for seniors everywhere. For more than three years, ASA has been arguing that patient safety was at stake, and now someone has listened."

Under federal law, HHS must seek public comments on the new rule before making it final. The long-standing supervision requirement thus remains in effect, and Medicare and Medicaid beneficiaries will continue to be guaranteed a physician's involvement in their care. Suspension of the Clinton rule will continue for at least the next six months, HHS has announced.

"We are absolutely confident that when the new rule from the Bush administration takes effect and when the scientific facts are known to the individual governors, they will do what is best for the people of their states ? retain the supervision requirement for their senior citizens," Dr. Swissman continued.

"Consistently, over 80 percent of seniors have said in several nationwide surveys that they want a physician involved in their anesthesia care -- and I know the governors will heed that message," Dr. Swissman said.

Since January 2001, more than 100,000 e-mails, faxes, postcards and letters have poured into HHS and the White House asking the administration to retain physician involvement in Medicare patients? anesthesia care.

Virtually all state laws and regulations require a physician to be involved with nonphysician providers in the delivery of anesthesia care. "I cannot imagine," Dr. Swissman said, "that the governors will not adhere to this pattern in the case of the most vulnerable class of patients, our senior citizens."

To ensure that their safety would not be jeopardized, Dr. Swissman explained that ASA has been fighting the no-supervision rule since it was first proposed by the Clinton administration in December 1997. He expressed gratitude on behalf of the more than 36,000 ASA members for the seriousness with which the Bush administration approached the issue of whether to overturn the Clinton rule.

"This administration has proceeded with the utmost caution and has wisely left in place a federal requirement for physician supervision," Dr. Swissman said. " The nation?s seniors owe this administration a big vote of thanks for protecting their anesthesia safety."
 
Meandragonbrett, what is your point? Do you expect everyone to sift through all of that to find the important information? You could have summed all of that up into one or two concise paragraphs. Many of the "studies" comparing CRNA's with MDA's were done by individuals with an agenda. I spent seven years in research, and I know how easy it is to manipulate the statistics to make the numbers come out right. I also have read some of these "studies" in CRNA journals, and many are simplistic and poorly designed to achieve a desired result (however, I won't get into that in the interest of brevity).
 
For the people who aren't in medicine yet. If'll you'll notice. These people totally ignore the debat of AA's. If you're wondering why, it's because their group, the ASA, supports AAs. Just remember that those AAs are going to come back and bite you in the butt someday. "just like everybody else has" Just remember that.

I'm out of here. I'm not wasting anymore time on you *****s
 
Members don't see this ad :)
It's going to take a while to read through all of that, MDB. One thing that did catch my eye, though, was the comment about decreasing insurance premiums. The decrease in premiums is due largely to advances in the anesthesia equipment, not necessarily due to the quality of the CRNA.
 
well, I have to say it has been more than slightly entertaining readig this thread over the last week.
I think we have somewhat of a mix of people in here although mostly I am sure it is med students and residents. (which is appropriate given this is a medical site)
I am embarased for medicine that one less educated individual who is calling names. (please)
MD's and RN's have built health care together. I get the feeling that some of you feel that the word NURSE means nothing more than ASSISTANT. early on in nursing the AMA tried to make nursing follow under the medical practice act. Nurses refused and have fought an uphill batte ever since (and rightly so) the important thing to understand is they are seperate enteties. Nurses study Anatomy and advanced Anatomy advaced physiology and advanced pathophysiology just as much as medical students
the diffrence exists in the model; medical model vs. Nursing Model pharm wise Nursing take plenty of pharm classes. they are after all the ones giving the drugs.
Nurses do research in fact there are vast libraries full of research. much of which has been used by medicine and other diciplines and have contributed. in fact, Nursing research is more accurate in some ways because they always use a theoretical frame work meaning the rearch is always based of previous research. in medicine any guy with an idea can write a grant.
lastly if anyone can interpret data from a swan its a nurse. Nurses are the high tech end of all this monitoring. I am an RN in an ICU. how any residents have seen that didn't know what wave looks like during a good wedge. and thats alright. we all have to learn. please dont stab nurses in the back there are plenty of jobs out there. you'll all get your.
did you know to beome a crna it takes 8 years of school. if you talk to a MDA that did not have bacholors before he entered med school you are looking at virtually the same number of years.
word.
 
Mr sandman- I agree with most of what you say, however, how did you come up with 8 years to be a crna?
bsn=4 years
crna=2 year grad program after a few years working as a ccrn
4+2 =6
are you counting the time working as an rn?
MDA: 4 yrs bs
4 yr md/do
3-4 yr residency
4+4+4=12
no offense to crna's intended. I work with a lot of good ones.
 
Mr. Sandman is living in a fantasy world where non-physicians try to fudge the numbers and make it look like they are equals in some way. Nurses DO NOT STUDY PATHO, OR ANY OTHER BASIC SCIENCE TO THE DEPTH THAT PHYSICIANS DO, regardless of the model. The nursing model in my humble opinion has always been a model that cut corners and made the educational ride smoother for the nurses taking the courses. You simply cannot simplify basic science courses under any guise and call the programs equal. I will give you credit, because you made one accurate statement. That was the fact that CRNA's do study advanced basic sciences, but so do PhD's, PA's, NP's, and many others. None of which are equal to MEDICAL SCHOOL. Do you know how may people get into medical school without a BS? It is so small that it doesn't even warrant discussion, and definitely should not have been the brunt of your argument. Most MDA's have literally twice the education as a CRNA, and each and every one of those years is harder than the most difficult year a CRNA ever goes through. And please don't think that because you can interpret a Swan Ganz that it makes you better. As a PA, I can close a wound as well or better than any of the doctors I work with, but that doesn't mean I am their equal. It just means I speant more time mastering one skill. You can teach a custodion to do a PAP smear or teach a child to do an ABG. I used to think a lot like you until I realized that the best way to be as good as a physician was to be one.
 
Mr. Sandman: "in fact, Nursing research is more accurate in some ways because they always use a theoretical frame work meaning the rearch is always based of previous research. in medicine any guy with an idea can write a grant."

Regarding the above quote, this is 100% false. I obtained a PhD and worked in medical research for almost 7 years. Medical research is ALWAYS based on previous research; it's called the scientific method, in case you haven't heard. I don't doubt that nursing research follows the same principle. I have no evidence to state whether medical or nursing research is "more accurate," but I do know that the majority of the most relevant and significant scientific/medical data is published in medical journals. I won't bore you with an infinite number of examples. And yes, any guy with an idea can write a grant, but no one is going to fund the research unless the idea is scientifically sound.

To PACmatthew: the last few sentences in your post are freaking brilliant, especially the last one.
 
Sandman - I took senior nursing pharmacology and pathophysiology in college. At the same I helped teach anatomy to the nursing students. To imply that these courses are anywhere near the caliber of the corresponding medical school couses is absolutely ridiculous. The nursing model teaches alogorithmic medicine (if pt has A, then do B) and only requires the most basic understanding of scientific principles. While nurses do serve an important role in health care, don't inflate that role into something it is not and never will be.
 
PAC has hit the nail on the head! I used to think I was a genius on the ward while doing rounds as the pharmacist, ridiculing physician's decision in my mind, but until you're in that role, the allied health professional has no idea what is involved or the multitude of complexities that factor into decision-making. I see that now in med school.
 
Sandman, i hate to burst your bubble man. The physio,pathophys, and not to mention anatomy somene at my schools BSN program gets is a joke. My roomate is a BSN senior in the program and I see what his tests are like and I routenly help him study for it. The anatomy is a joke, and the physio is little more then what you can take at any undergraduate college. Dont even get me talking about the Path. I know a lot more of the basic sciences then he does. The only place that nurses have any more trianing then your typical undergrad who has an A&P concentration is the clinical stuff they get to do. Sorry if this post is a little incoherient, I was studing for a final all last night.
 
Sandman...never mind...it is not worth it. Your logic is the same the RN's use on the floor during gossip hour...which is every hour.
 
Meandragonbret,

Thanks for flooding the thread with CRNA propaganda.

Next time, please post a link to the AANA website....like this:

<a href="http://www.asahq.org/homepageie.html" target="_blank">http://www.asahq.org/homepageie.html</a>

-TRG
 
What are we debating. whether nurses are smarter than docs or visa versa. no. or at least thats not my intent. I think both contribute important things. I only wanted to despel the dumb nurs garbage.
the truth is this debate is rediculous your never gonna say " ya I can see your point why I am I so far in debt". and vise versa.
let explain my reasoning on the years. I did leave a part out
2 years hard science pre req
4 years nuring school/ med school
2-3 years residency/ grad school
= 8 to 9 years
both....
say you did have a bs before you went to med school most are physc or socioloty or some other non thinking major. true some may be biolgy but not the majority.
did you know physcology is the fastest major you can get..
 
Well good grief, with the lofty opinions people have here about nurses no wonder there's a nursing shortage! Or I guess only the dumb inferior IQ ones actually are the only ones silly enough to slog through nursing school :p
 
•••quote:•••Originally posted by Mr. Sandman:
•
let explain my reasoning on the years. I did leave a part out
2 years hard science pre req
4 years nuring school/ med school
2-3 years residency/ grad school
= 8 to 9 years
both....
say you did have a bs before you went to med school most are physc or socioloty or some other non thinking major. true some may be biolgy but not the majority.
did you know physcology is the fastest major you can get..•••••I'm not sure where this person is getting their information....
I don't know anyone in medical school without a BS...I believe it is required in 99% of the cases...Actually, there are many people in my class with master's degrees, MPH, PharmD's, etc...

So that is 4 years undergrad minimum.
Then medical school is 4 years period.
Residency is AT LEAST 3 years long at a minimum, up to however long you want to go say 7-8 years.
Anesthesiology is 4 years minimum.

A BSN would be a 4 year program.

I was speaking to a CRNA student the other day, and she had said that she would complete her degree in 18 months...which is not even 2 years...not sure where the 2-3 years of grad school quoted above is from.

I really dont think they are equivalent...

TRG
 
Sandman dude, you are just making nurses look more ignorant by continuing to talk out of your a@$. Oh yeah, learn how to spell before you say nurses and doctors should be regarded in the same sentence.
 
This may sound egotistical but... ahhh whatever... I say we just ignore what the RNs have to say on this thread or otherwise. That's what I do in the hospital anyway :p .
 
It's kind of nostalgic to see another one of these MD vs RN threads. Do nurses actually believe that haphazard grapeshot cannon evidence will sway the opinion of a community of physyicians and physicians to be?

I actually made the mistake of trying to cogently refute the spam on another thread by citing the only reputable study comparing level of care between a CRNA and an Anesthesiologist. It was my hope that the nursing community would demonstrate all this great 'knowledge' by offering up a cogent and well substantiated rebuttal. All I got was rubbish and spam. The reply speaks volumes.

Good Grief
 
obviously I don't expect you guys to see my point. but, plenty of legestlators have and so also the community.
professions evolve. surley you didn't expect nurses to be walked over forever. just as medicine has evolved so does nursing.

its the PA's that are the question in my mind. no experince. a two year program. they want autonomy right??.. whats exacty does the name assistant mean.????
p.s. if nurses ever do get into neurosurgery I'll be the first one on board. I love that stuff.
 
•••quote:•••Originally posted by Mr. Sandman:
•obviously I don't expect you guys to see my point. but, plenty of legestlators have and so also the community.
professions evolve. surley you didn't expect nurses to be walked over forever. just as medicine has evolved so does nursing.

its the PA's that are the question in my mind. no experince. a two year program. they want autonomy right??.. whats exacty does the name assistant mean.????
p.s. if nurses ever do get into neurosurgery I'll be the first one on board. I love that stuff.•••••Mr. Sandman,

As others have pointed out, you are grossly misinformed, especially regarding 'the legestlators'. To keep it simple for you, Clinton signed an eleventh hour torte that would have granted CRNA autonomy in rare and guarded circumstances. The instant Bush assumed the reigns of control, this bill was squashed. End of story. As you can see, 'the legestlators', at least here in the US, have actually worked actively to squash reform that empowers CRNA autonomy.

You can keep talking about 'legestlators' until your blue in the face. It doesn't change what is supported by the factual account. I have said it before to others of the delusional persuasion; feel free to bury your head in the sand, it's a free country.

K.P.
 
I think the Sandman needs to spend less time inserting Swan Ganz's and spend more time diagraming sentences, inserting sentence breaks, and speaking coherently. Now I know I cannot spell for shi%, but spelling doesn't correlate with potential. Now flat out communicating does though, so please Sandman, clearly outline your ideas before moving to the next stumbling block. The majority of medical students have a BS, and that BS is a biology major most times, followed second by chemistry, and then other. Yes, a psychology degree will get you into med school, but not before you do your pre-reqs which most psych majors never do until post bacc. That adds another year or two. RN school is 2 years only, and the BSN programs either admit people into year number 3 with pre-reqs (hardly hard science by the way), or they are flat out four year programs that don't start RN coursework until after year 2. When nursing students have to enter the nursing profession after taking organic chem, physics (not physics for health professions), real Bio I and II, and Gen Chem, then you can say they have hard science equivilants of premeds. Sandman, my recommendation would be that you clarify all data you recite and reference it. It is simply untrue and you are doing all that read this forum a disservice to say the things you say. Bottom line, a CRNA could potentially get done with their education in as short as 5.5 years, while an MDA has a minimum of 12 years. I was being kind when I said that an MDA was twice as much school, but as you can see it could be even more. Zero comparrison. And outcome data about CRNA's is not an accurate way to assess if the profession is one that is safe or not for patients. These days a CRNA has more lattitude than an anesthesia resident. Why don't we just create multiple professions where people do the job of physicians and simply not have physicians? We could have midwives deliver all babies, PA's see all primary care patients, and surgical assistants do all the surgeries. I am sure you could teach each one of these individuals how to do their jobs well enough to succeed, but if even one mistake happens, that is a bad outcome. One bad outcome might not reflect in a p-value statistical model as relevent, but would that one mistake have occurred if it were a physician? If my wife is on the table and dies for some reason, it better be a physician that comes and tells me they did everything they could do, because anything less would leave more than reasonable doubt in my mind. Get the picture?
 
Sandman,
i dont think anyone here is disputing who has higher or lower IQ. However, everyone here has been through something you have absolutely no clue about. I have seen this first hand. SOme nurses have very little idea of what MDs go through until they actually see it for themselves. Before you, or any other nurse writes a response, I would advise you to do this. Take one morning off from your life saving procedures, and go sit in a 'freshman medical class.' This is where the torture begins. I guarantee you will comprehend. We can all write a thousand responses to ignorant and jealous garbage. However you will never understand until you see what we go trough firsthand. I swear there is more in Netter's atlas alone than in your entire nursing education, just go to a medical bookstore. What I'm trying to say is that before you start composing your jealous b.s. try to understand the enormous educational differences.

As someone has pointed out already, even the pre-requisites for medicine are twice as hard. My college roomate went into nursing...give me a break! Not only do pre-meds go trough hard classes, they have to maintain an incredibly high GPA! And where you get your info from i don't know, but in my medical class there are about 95% science majors...

By the way, there is an RN in my class, he's a genius, he keeps a 4.0 average...so intelligence is hardly an issue.

Although I'd be so glad to see a new wave of brave nurse's aides who want to start IVs and do whatever RNs do in the hospital...that way you'd see how ridiculous RNs sound talking about our field of medicine.
 
•••quote:•••Originally posted by Neurogirl:
•Ryo-Ohki,

Unionizing has absolutely nothing to do with "common sense". But then, if you knew anything about the practice of MEDICINE, you'd know that! The purpose of unions is to gain bargaining power by using the ultimate threat of strike. Physicians haven't unionized because we won't strike. How would you feel if you or a loved one needed urgent care but the doc said, "sorry, I'm on strike"! Our oath (committment to humanity) prevents us from withholding care for the sake of money. Nurses, on the other hand CAN strike since there are always physicians available to handle care if necessary.•••••Wrong!

There are actually sparse physician quasi unions circulating under the cover of darkness. In large part, physician unions don't exist because they have been declared illegal.

I assure you that many many physicians have tried to unionize, and will continue along these lines. For the moment, court has prevented unionization, not 'the oath.'

In fact I would argue that failing to appreciate the necessity of unionization is actually counter-oath, as medical care has fallen into shambles, leading to poorer care for our patients.

Food for thought
 
•••quote:•••Originally posted by Mr. Sandman:
• p.s. if nurses ever do get into neurosurgery I'll be the first one on board. I love that stuff.•••••LOL. That's great stuff. <img border="0" alt="[Laughy]" title="" src="graemlins/laughy.gif" />
 
Sandman, if you want to do neurosurg then go for it. You seem to think that a nurse's education is just as difficult as an MD/DO, then you should have no problems getting in and staying in med school. The next MCAT is in august. Put your money where your mouth is. We'll see if the watered down Chem/Ochem, Physics, and Bio are enough. Good Luck pal.
 
Sandman - My uncle is training to become a CRNA right now. His requirements: 1 year of an accelerated nursing program + 1 year mandatory ICU work + 2 years in a CRNA training program = 4 years total. I start an anesthesiology residency program next month. My requirements: 4 years for B.S. in Bio Sci + 4 years medical school + 4 years residency training = 12 years total. Does this sound equivalent to you? Let me know if you need help with the math.
 
Say what you will or may..the concern for anyone is that the patients recieve the best possible care for the greatest outcome. I believe that ANYONE who endures the education,the stress,the time of school deserve to be compensated likewise.
To that end I believe that 120 + is a lot of money for a CRNA.I would dare not "dog" the nursing profession as my sister was a nurse.But she too had plans on going to medical school before her death.She had been a nurse for over 8 years and was simply not satisfied.
If given the opportunity what person in their right mind would not opt for the one who was more experienced to help their loved one? Let the CRNA's salary skyrocket..fine. But just let anesthesiologist's -who went to MEDICAL SCHOOL-
salary skyrocket as well.
As someone who plans to go into OB-GYN,you better believe I would see something wrong with a nurse midwife making more money than I would.Hey here is an idea why don't we let the pharmacy technicians make more than the pharmacists;or the nurses make more than the physicians,or the substitute teachers make more than the full time teachers.
To those of you who said the credentials should speak for themselves...you would think that they would but apparently they don't.
What is wrong with wanting to make a living after medical school? The loans are astronomical...I have a friend who went into OB-GYN and had to close down her practice.
I am not doggig or putting down anyone's profession.If you love what you do and have found your niche in this mixed-up world,kudos to you.
The bottom line should be to help patients recover their health to the best of your ability.
 
•••quote:•••Originally posted by drfeelgood:
•KIMYA.... (Hope you got your Asbestos Suit on cuz here it comes!!!!)

It's not all about money. It's about the way Americans have settled for the CHEAPER ALTERNATIVE. we're being invaded by middle-men. I heard Kaiser is now starting Nurse Endoscopy school...So watch out all you budding GI DOCS. What next??? Residency training for the primary-care PA??? There are plenty of jobs that pay more than Medicine, I'm not arguing that. I get pissed of when wannabes try to play doctor.

Why not fly on a plane flown by an Certified Pilots Assistant????? Hell...anyone can land an aircraft. Wouldn't that be cheaper??? I'm glad the ASA is finally fighting back against the CRNA lobby. :clap: :clap: •••••This flame suit seems to be holding up pretty good so far.. :wink:

I don't think this is a business of wannabes versus non wannabes. This is a matter of economics. Several posters have described how midlevel providers like CRNA's got started (i.e to fill a need in areas where doctors did not WANT to serve). Now they are expanding to other areas as well. If they are competent to serve in underserved areas, why exactly are they not competent to serve elsewhere? Ah yes, the almighty dollar. Fact is, nobody cares in the business world (and medicine is a business) how long you went to school or how hard you had to work to get there. If there is someone who can competently do a portion of what you are doing for less, you can bet that that is going to happen. If you don't like it, than organize and prove which areas you feel should be your domain only.
 
Read up the section on match 2002 in the ASA news letter, its likely that there will be a CRNA shortage right in time for an increased # of MDA graduating, well the fact is that if CRNAs and MDA keep cpmpeting neck to neck for the same job the CRNA will get it for he/she is cheaper. This might force MDs to not choose anesthesia. God forbid in the event that they completely edge us out as someone said in the business world nobody cares how long you go to school what matters is that what you can give in return for a fee. CRNAS are cheaper now....if they edge us out they still will not bring down the overall cost of anesthesia care, they will only replace it with a comparitively substandard means of care having edged out MDs. So patients will overall still pay only now they will only have nurses. Scary. Should this happen other para professionals will slowly take over and the whole of the medical profession wil be repalced by crash course docs. Really scary( hopefully I will not be on medicare at that time). With the goverment going so soft on this invasion of the nurses and cheaper alternatives to docs. I will not be suprised if soo we have a Dummies series to be a doctor!! <img border="0" title="" alt="[Eek!]" src="eek.gif" />

The only solution is to ask the Public, when i told some people recently that nurses can do anesthesia unsupervised they were shocked. If the public had to vote on this they would clearly refuse thier care being handed over to nurses.
 
Halothane,
Did you happen to mention that CRNAs aren't "Staff Nurses" *no offense to any* and that they have more training than other nurses? I find it hard to believe that you did. And also, you are incorrect about CRNAs not being supervised, They are supervised, just not by a MDA they are supervised by the operating physician. Great information you're giving out to these folks. Maybe that's why they are all scared because you aren't giving out the correct facts?
I said that would be my last post earlier, but I just couldn't resist this one. The resident and student gene pool could you a dose of Chlorine.

Brett
 
•••quote:•••Originally posted by halothane:
•I will not be suprised if soo we have a Dummies series to be a doctor!! <img border="0" title="" alt="[Eek!]" src="eek.gif" />
•••••LOL!
I remember reading about surgery in the pre-anesthesia era. Apparently, the only real "surgery" performed was limb amputation. If I recall correctly, it went something like this...

The patient with, say, the gangrenous lower limb, would be advised by the surgeon that, if he didn't want to go septic and die, he would have to undergo surgery. As you can imagine, choosing b/w a septic death vs. amputation without anesthesia was... well, a difficult decision for the patient. Nonetheless, most patients chose surgery. On the day of the scheduled operation, the patient would be wheeled in to the "OR," where he would be "welcomed" by the doctor plus 4 very big burly men. At this point, the doctor would ask "Shall we proceed?" If the patient lost his nerve and said no, no harm done... he'd be taken back to his room no questions asked. If however, he even uttered a soft, barely-audible "yes," this was considered the point of no return. Immediately, the 4 muscle men would grab him firmly and hold him down on the operating table. The doctor would grab his equipment (I'd imagine some kind of saw), and regardless of what the patient said (or screamed) at that point, he would proceed with the "operation." Luckily, the patient would usually become unconscious from the pain/exhaustion half-way through the procedure. It comes as no surprise then, that Surgeons in that era were judged by their speed.
My point? If I were that patient, if I had gangrene of my leg, if death was imminent for me, and I HAD to go to surgery... I'd choose the 4 strong men over a CRNA any day :D .
 
dragonbrett,

Do you think it makes any of us feel better to know that a CRNA is supervised by the surgeon? I mean come on, we all know that surgeons and anesthesiologists have way different agendas. The most important thing to the surgeon is that the patient not be moving and that he wake up at the exact time that the last stitch is placed. There are supposed to be two different PHYSICIANS in the OR so that the patient has an advocate, and the pathology has an advocate. Combine the two and you lose the patient advocate.
 
mr sandman-you are a little misinformed about the p.a. educational process...
to get into a typical p.a. program you need
1. a bs degree: the trend is for pa programs to be at the masters level now(4 yrs)
2. training in another field( rn, paramedic, resp. therapist, etc.)
3. 3-5 years experience in field above.
I was a pretty typical student in my class. my stats:
bs from university of california (4 yrs)
paramedic program( 1 yr)
5 years working for a 911 system as a paramedic
ms in pa studies( 2 yrs for bs#2, 1 more for ms)
postgrad program in emergency medicine(1 yr)
that's 9 yrs of school.
 
This is the Mother of all threads!!!

I'd pay to watch MeandragonBrett and Halothane FIGHT!!!!! LOL <img border="0" alt="[Laughy]" title="" src="graemlins/laughy.gif" />
 
what is it that makes this thread so hostile?
has anyone ever thought about how our professions differ from other real world profesions.
I think its hostile because we are all sensing the competition of it all. really what do any of you care how much a crna makes. if you choose the right specialty you could make much more. six figures isn't what it used to be. if i make 130 grand and the neruo surgeon makes 700 grand thats fine with me and it should be fine with him.
personaly by time I become a CRNA it will have taken 8 years total. maybe thats not 100% the case. these 18 month programs don't exist any more. nurses don't use log rthyms PA's truly do. Nurses use critical thinking. don't tell me its not true unless your a nurse and you've stood at the patients bed side titrating dripps all day. unless you've had to convice a residnet to change the pressor from an alpha to beta to get more cardiac output. unless you've used your gut feeling to know when a patient can be extubated or not. I've held the hand of dieing people. some have asked me if they were dying. I've hugged family members in the hall. I know that anesthesia starts the second you meet that patient and not when you give the drugs. I 've done these things for years and not for the money. just like every other nurse has.
has a nurse been mean to you? I am sorry. some are passive aggressive and they get their licks in when they can. As more men come into nursing there will be less of this. pick yourself up and carry on. the hospital is a hotile environment I don't think any of us like that aspect.
the residents I work with for the record are stand up guys. I have never met better more true medical practicioners. they are all neruo surgeons (maybe that has somthing to do with the calibur) they work very closely with nursing staff. they trust us for our specialty and in turn I trust them. I go to lunch with them. I watch them party at night. it is an awsome relationship. and, I think they benifit. if one of my friend residents are on call I do everything in my power not call them at 0200. on the other hand they know If I do call its serirous.
so I've blabed a bit I think I feel bad for the tone of this thread. who we should be fighting are the insurance compainies and large hospital corporations. and MBA that tell us how to treat patients. not each other.
 
Have you all considered that "Mr. Sandman" is most likely some smartass high school student who is just busting all of your chops?

Again, can we please just let this discussion fade into the distance, where it belongs?
 
Look, I really want to be a surgeon--(starting the residency and everything)--you DO NOT want a surgeon running the anesthesia on any case. Pretty much the only time a surgeon will even notice the anesthetist in the room is when the sh$t hits the fan. By that time, you are headed down a slippery on a rocket powered sled with greased runners. Bottom line, there needs to be a second physician in the room during an operation whose job it is to keep the person alive while I muck around in his guts.
 
don't worry iam done with this site I am not comming back. to post anyway it just brings us all down.
I must say this last thing because I am interted on weather anyone has any worthwhile takes.
have you considred the great injustice done to society by medicine for centuries. As I watch patients they are afraid of medical practioners. they feel like they have to call them Doctor. what is that. paients have been made to fear doctors for centries my own mother is afraid to ask her doc a queston becuae she doesn't want to waste his pressious time. how many people have died because of the pseudo class diffrence. why have you insisted that your patinets call you doctor. your not even really doctors your about the equivlant of a BS doctors do research. you are a medical practioner. and really pharmacist with phd'd should be the doctors of medicine see how its all jacked up.
do you know that in my state their exists 2500 doctors and 17000 nurses when nurses are ready the lobying will be a cinch.
 
•••quote:•••Originally posted by Mr. Sandman:
• have you considred the great injustice done to society by medicine for centuries. As I watch patients they are afraid of medical practioners. they feel like they have to call them Doctor. what is that. paients have been made to fear doctors for centries how many people have died because of the pseudo class diffrence. why have you insisted that your patinets call you doctor. your not even really doctors your about the equivlant of a BS doctors do research. you are a medical practioner. and really pharmacist with phd'd should be the doctors of medicine see how its all jacked up.
do you know that in my state their exists 2500 doctors and 17000 nurses when nurses are ready the lobying will be a cinch.•••••Haha....all you can do is laugh at comments like these because no one takes them seriously
 
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