Short history of nurse anesthesia and future of anesthesia care (written by MD)

[deleted697535]

Great point modanq.

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[anbuitachi]

I also think we should step up to the plate. We should change the dynamics and understanding of what anesthesiologists do.
What are your thoughts on the following ideas...
1. We should have standard education in Echo both TEE and TTE.
All residents in anesthesiology should graduate with board certification in both surface and cardiac echo. You can use TTE as point of care. Instead of randomly giving fluids figure out how much a prepped-NPO-bowel obstruction patient needs. We can bill for ultrasound and it makes us indispensable.
2. Our residents/attending shouldn't be wheeling patients into the OR...really can't believe we still do that. We should be managing the OR managing the medical needs of the patient.
3. In our PA run pre-op anesthesiology clinic we can do our own TTE and manage pre-op medication management. What the hell is the MD degree for. Why do we need to send the patient to cardiology for B-Blockade titration pre-operatively. Or holding prils. Why does the PCP need to schedule patients for stress testing??? We can run our own TTE clinic and complete that in anesthesia clinic.
3. We should create education pathways for MD only in ultrasound blocks and catheter placements. This should be logged and more nuanced in the ACGME log book. That way it is stiffer for credentialing at the hospital level.
4. We should subsume ICU care into our standard of practice and core residency. Yes we may lose some $$ and not everyone is interested in ICU but our clout in the hospital will grow. At my institution the anesthesiologists run the ECMO service, the trauma transport team, and also the ICUs.
5. Why are we considered the PIV experts but never learn how to place PICC lines. We should supervise a line vascular service prob RN run but the tough cases should come to the MD.
6. The pain services should be hospital wide anesthesiologist run. It will initially be more work but in 15-20 years when we own methadone, PCAs, narcotics, ketamine etc... like we own propofol we can be leaders in all areas of the hospitals.
7. We let neuromonitoring slip right in front of us? I always wonder why we claim to be expert monitorists in the OR however when it comes to SSEPs the tech reports to a Neurologist. How did we let these folks into our own ORs???
I hate to admit but some older MDs got lazy. We should be billing for SSEP and MEP monitoring.
Its important to step up to the MD title.
Just some ideas that I think will broaden the scope and respect of the anesthesiologist. CRNAs should exist just like the ICU nurses, we need to broaden the things we do...We just can't sit in a chair for a 10 hour case and clock out.
Just my two cents.

We have a line service run by ICU fellows that we as residents spend 1-2 weeks on. We do central lines including PICCs. They aren't special at all.. But they are increasing the standards for new grads with their new OSCE exam... hahahah

 

[peltier]

https://www.linkedin.com/pulse/crnas-short-history-nurse-anesthesia-future-care-matthew-mazurek-md

Hmm, after reading the article (and supposedly he's from all MD anesthesia practice in Arizona).

The real question is wonder is whether his group is about to sell out to a management company soon??? Cause if they are from all MD group and he's promoting CRNAs. Those are tell tell signs they may be selling soon.

Just a hunch.

Cause Sheridan/Amsurg/Envision brought the other huge group in Arizona a couple of years ago.

As the author of the article, I can assure you the model for anesthesia care is undergoing rapid change and already has started throughout the US and abroad. As I stated in my article, 47 CRNAs are now practicing at UCSF in a care team model, which represents nothing short of a massive expansion of their role even in an academic setting. I haven't even touched on Anesthesia Assitants yet, and that is coming next. I expected a blistering response, and I received it, which is proof of the contentious nature between CRNAs and MDs.

 

[deleted126335]

As the author of the article, I can assure you the model for anesthesia care is undergoing rapid change and already has started throughout the US and abroad. As I stated in my article, 47 CRNAs are now practicing at UCSF in a care team model, which represents nothing short of a massive expansion of their role even in an academic setting. I haven't even touched on Anesthesia Assitants yet, and that is coming next. I expected a blistering response, and I received it, which is proof of the contentious nature between CRNAs and MDs.

-I don't think that anyone needs anymore evidence of the contentious nature between CRNAs and MDs.
-No question that roles for CRNAs are expanding. This is because money is tight and everyone is desperate to shave on costs wherever they can.
-The AANA has been singing he same song for decades. They are only now gaining ground because the economic pressures have never been higher.
-You will have to forgive those of us who spend the majority of our time supervising CRNAs for actually believing that we make a difference.
-You will have to excuse the anti-CRNA sentiment that many of us have because their professional organization says that what we do when we supervise doesn't matter. Or that solo CRNAs are virtually interchangeable with solo MDs or an ACT model

 

[peltier]

Like I said. Something sounds very fishy. He's the new "chief of staff elect" at his hospital.

It's either a setup for future use of Crna at their practice. Out west as we all know many of the groups are all MD and that's all surgeons are used to. So will look at Crna's with skepticism.

It's funny how some Crna's in the South I know say surgeons don't want MDs in the room and only Crna's. So it's who the surgeon is comfortable with.

And I am not a 'new' Chief of Staff, Elect, as I have been in this position for nearly two years and Chair of Anesthesia for 6 years prior to that. Also, if you investigate anesthesia care team models across the US, you will clearly see either MD directed models or independent practitioners from both the CRNA and MD trained programs working side by side. I didn't create this model for care, but it's obvious it works otherwise it would have evaporated years ago.

 

[aneftp]

And I am not a 'new' Chief of Staff, Elect, as I have been in this position for nearly two years and Chair of Anesthesia for 6 years prior to that. Also, if you investigate anesthesia care team models across the US, you will clearly see either MD directed models or independent practitioners from both the CRNA and MD trained programs working side by side. I didn't create this model for care, but it's obvious it works otherwise it would have evaporated years ago.

So UCSF lets a brand new SRNA grad runs his/her own ASA 4E cases in the middle of the night? Is that what you mean by crna and md working side by side?

This is where the AANA propaganda machine works. They say MD and CRNAS receive the same exact training. What better way to example safety than to test UCSF new MD grads vs. new UCSF SRNA grad consistency doing ASA 4 cases solo?

Why don't programs do this???

You get my drift? There is a lot of selection bias with "safety". Are CRNAs safe? Yes. Most of us on this board aren't questioning the majority of crnas are safe. But many of what crnas do is essentially on the job training. Very few "new grad" srna doing solo complicated cases.

I do know a few out in rural parts of northern California, parts of rural oregon doing "solo" crnas as a fresh grad crna. They ain't doing ASA 4 cases cause those cases get punted to tertiary care center.

 

[aneftp]

As the author of the article, I can assure you the model for anesthesia care is undergoing rapid change and already has started throughout the US and abroad. As I stated in my article, 47 CRNAs are now practicing at UCSF in a care team model, which represents nothing short of a massive expansion of their role even in an academic setting. I haven't even touched on Anesthesia Assitants yet, and that is coming next. I expected a blistering response, and I received it, which is proof of the contentious nature between CRNAs and MDs.

I've been in academics. The reason for the expansion of the CRNAs in academia is purely financial since residents cannot be billed 1:4.

If academics does bill "independently' crna work, it's usually in endoscopy where the anesthesiologist isn't physically "in the location" immediately available so it's billed as Qz modifier. But the anesthesiologist is available.

 

[Man o War]

So UCSF lets a brand new SRNA grad runs his/her own ASA 4E cases in the middle of the night? Is that what you mean by crna and md working side by side?

This is where the AANA propaganda machine works. They say MD and CRNAS receive the same exact training. What better way to example safety than to test UCSF new MD grads vs. new UCSF SRNA grad consistency doing ASA 4 cases solo?

Why don't programs do this???

You get my drift? There is a lot of selection bias with "safety". Are CRNAs safe? Yes. Most of us on this board aren't questioning the majority of crnas are safe. But many of what crnas do is essentially on the job training. Very few "new grad" srna doing solo complicated cases.

I do know a few out in rural parts of northern California, parts of rural oregon doing "solo" crnas as a fresh grad crna. They ain't doing ASA 4 cases cause those cases get punted to tertiary care center.

What does it mean for a CRNA to be safe? THAT is the crux of the matter.
Here's my litmus test: if me,my wife, children, or any loved one is scheduled for surgery, would I be cool with a solo CRNA? The answer is NO. I've seen enough to know their limitations. I want an anesthesiologist either sitting the stool or immediately available if something terrible happens. This cannot be guaranteed in these "collaborative" models since the MDs are doing their own cases.
Of course there are bad anesthesiologists, just as there are bad surgeons and docs in every specialty....but if I'm picking blind, I want an anesthesiologist. So I guess I'm saying I wouldn't feel that it is safe to have anesthesia with only a nurse in charge.

 

[dhb]

And I am not a 'new' Chief of Staff, Elect, as I have been in this position for nearly two years and Chair of Anesthesia for 6 years prior to that.

Since when have you been a clown?

 

[Arch Guillotti]

Please keep it professional. Thanks.

 

[Timeoutofmind]

And I am not a 'new' Chief of Staff, Elect, as I have been in this position for nearly two years and Chair of Anesthesia for 6 years prior to that. Also, if you investigate anesthesia care team models across the US, you will clearly see either MD directed models or independent practitioners from both the CRNA and MD trained programs working side by side. I didn't create this model for care, but it's obvious it works otherwise it would have evaporated years ago.

The problem is that the "respect goes both ways" would be a great solution if it were true.

Unfortunately, the CRNAs as AN ORGANIZATION, have no intention of "respecting" anesthesiologists. Or the concept of limits of any sort on their end, or of our specialized training. Instead they would like to practice without supervision, even in areas where they clearly have inferior/no training, and continue to pursue an aggressive political agenda as such. In case you think this is an exaggeration, just stop and consider that CRNAs are trying to make inroads in interventional pain management. Horrendous. And so unsafe and sad.

It is not an issue of respect going both ways. It is an issue of reigning in delusional and unsafe political efforts for the sake of patient safety.

Please become a part of the solution instead of the problem. Your article is irresponsible.

 

[dhb]

Please keep it professional. Thanks.

Well i though he was funny. Clown is kind of mild imho.

 

[deleted480308]

As the author of the article, I can assure you the model for anesthesia care is undergoing rapid change and already has started throughout the US and abroad. As I stated in my article, 47 CRNAs are now practicing at UCSF in a care team model, which represents nothing short of a massive expansion of their role even in an academic setting. I haven't even touched on Anesthesia Assitants yet, and that is coming next. I expected a blistering response, and I received it, which is proof of the contentious nature between CRNAs and MDs.

Do you think an avg crna is safe to step in and run full scope like the avg doc?

 

[sevoflurane]

Kinda funny. As far as I know, Southern Arizona Anesthesia Associates where this guy practices... is still ALL MD!!!

Oh... the irony.

 

[sevoflurane]

We are one of the largest groups in my state and we have refused to hire CRNAs due to the malignancy of the AANA and their rhetoric. It is because of the AANA that I have these feelings and I fully understand that not all CRNAs feel the same way.
If anything, our future will see AAs if we elect to convert to an ACT model. I just can not fathom inviting my enemy into my home and I refuse to plant a malignant seed in my living room.
We are doing just fine the way we are currently plus every patient gets a board certified (often times multiple board certified) PHYSICIAN ANESTHESIOLOGIST.

 

[Consigliere]

Kinda funny. As far as I know, Southern Arizona Anesthesia Associates where this guy practices... is still ALL MD!!!

Oh... the irony.

Not for long...

 

[DrCommonSense]

You fight on every front. You never know, you might get lucky. At least you make them spend resources. Just like they do to us. e.g., the recent attempt at an end run around the VA decision: American Society of Anesthesiologists - New House Independent Practice Legislation for VA Nurse Anesthetists

Yup it never ends with them. They will keep coming back again and again.

 

[DrCommonSense]

And I am not a 'new' Chief of Staff, Elect, as I have been in this position for nearly two years and Chair of Anesthesia for 6 years prior to that. Also, if you investigate anesthesia care team models across the US, you will clearly see either MD directed models or independent practitioners from both the CRNA and MD trained programs working side by side. I didn't create this model for care, but it's obvious it works otherwise it would have evaporated years ago.

Anesthesiologists with your philosophy is why the field is going down the tubes.

The militant CRNA is a result of Anesthesiologists who game the system for a fast buck and "support them" at the expense of everyone else.

Why would they care? After the ship sinks, they will be OUT with their money right?

 

[DrCommonSense]

https://www.linkedin.com/pulse/crnas-short-history-nurse-anesthesia-future-care-matthew-mazurek-md

Hmm, after reading the article (and supposedly he's from all MD anesthesia practice in Arizona).

The real question is wonder is whether his group is about to sell out to a management company soon??? Cause if they are from all MD group and he's promoting CRNAs. Those are tell tell signs they may be selling soon.

Just a hunch.

Cause Sheridan/Amsurg/Envision brought the other huge group in Arizona a couple of years ago.

WOW just WOW

This guy is truly UNBELIEVABLE

What is going to happen when we have "independent" CRNAs side by side with physicians doing cases?

Thats right, physicians will be PAID far less but remain with the SAME level of liability with likely INCREASED workload.

Sub 300 salary for Anesthesia makes the risk FAR TOO HIGH for the REWARDS for people who have a few million saved up.

Can always go back to do Neurology residency or just do 100% Addiction Medicine/Pain/Palliative at that Point if salaries drop too much with "independent" CRNAs.

Crazy times. Too many Anesthesiologists selling out the profession for a fast buck.

These same ones who are SELLING things out dont give a darn because they will make so much money they can just leave the profession if needed or be the luck few "directors"

 

[anbuitachi]

Yea it's really irresponsible how some anesthesiologists are so irresponsible towards their field and other anesthesiologists (especially new grads). Too many are selling out for a quick buck. Meanwhile AANA is a pretty united organization. It feels like we are battling two opponents, the AANA and those anesthesiologists who'd rather have CRNAs so they can make a quick buck. Like many said, do you really want a fresh CRNA taking care of your really sick patients.

 

[DrCommonSense]

Yea it's really irresponsible how some anesthesiologists are so irresponsible towards their field and other anesthesiologists (especially new grads). Too many are selling out for a quick buck. Meanwhile AANA is a pretty united organization. It feels like we are battling two opponents, the AANA and those anesthesiologists who'd rather have CRNAs so they can make a quick buck. Like many said, do you really want a fresh CRNA taking care of your really sick patients.

Its actually the OLDER physicians or "directors" that are making big dollars on this stuff that are selling out the younger generation of physicians/anesthesiologists.

I am VERY concerned that they will never stick up for the younger docs.

Probably just have to make sure to avoid doing anesthesiology in the future when it becomes a nursing field.

 

[anbuitachi]

Its actually the OLDER physicians or "directors" that are making big dollars on this stuff that are selling out the younger generation of physicians/anesthesiologists.

I am VERY concerned that they will never stick up for the younger docs.

Probably just have to make sure to avoid doing anesthesiology in the future when it becomes a nursing field.

Yea everyones doing fellowships to try to differentiate themselves... its sad. 1/4 of the class is doing pain.

 

[DrCommonSense]

Yea everyones doing fellowships to try to differentiate themselves... its sad. 1/4 of the class is doing pain.

Yeah I really don't see how OB/Neuro, etc would help.

The only ones that make any sense are Cards/ICU/Peds/Pain at this time.

CRNAs won't do complex cardiac or peds or run an ICU either.

However, if the CRNAs destroy anesthesiology by taking over all the "bread and butter" procedures, the salaries for ALL of OR anesthesia will be pushed down including the "complex" stuff because it will force other MDs to have to push into that market to maintain their salaries and "differentiate" themselves.

All MDs can't move into complex peds and cardiac due to them being a small percentage of cases overall. So, most salaries will be pushed down dramatically.

 

[aneftp]

Yeah I really don't see how OB/Neuro, etc would help.

The only ones that make any sense are Cards/ICU/Peds/Pain at this time.

CRNAs won't do complex cardiac or peds or run an ICU either.

However, if the CRNAs destroy anesthesiology by taking over all the "bread and butter" procedures, the salaries for ALL of OR anesthesia will be pushed down including the "complex" stuff because it will force other MDs to have to push into that market to maintain their salaries and "differentiate" themselves.

All MDs can't move into complex peds and cardiac due to them being a small percentage of cases overall. So, most salaries will be pushed down dramatically.

The complex peds and cardiac cases almost always usually referred out cause most have poor payer mix (Medicaid and or Medicare).

So MDs do more complex case for less money. It doesn't make sense. Needs to have a balance of cases.

AANA will keep driving the "value measured performance metrics". How crnas can save the system. They will use the global costs of anesthesia as a reference point rather than point out to specific high cost low reimbursement services (Asa 4 complex cases)

 

[DrCommonSense]

The complex peds and cardiac cases almost always usually referred out cause most have poor payer mix (Medicaid and or Medicare).

So MDs do more complex case for less money. It doesn't make sense. Needs to have a balance of cases.

AANA will keep driving the "value measured performance metrics". How crnas can save the system. They will use the global costs of anesthesia as a reference point rather than point out to specific high cost low reimbursement services (Asa 4 complex cases)

Yeah that is why MDs are total SCREWED if they give up the "bread and butter" stuff.

Who the F wants to do complex cases for LITTLE MONEY and HIGH LIABILITY? Screw that!

 

[flightnurse2MD]

https://www.linkedin.com/pulse/crnas-short-history-nurse-anesthesia-future-care-matthew-mazurek-md

Hmm, after reading the article (and supposedly he's from all MD anesthesia practice in Arizona).

The real question is wonder is whether his group is about to sell out to a management company soon??? Cause if they are from all MD group and he's promoting CRNAs. Those are tell tell signs they may be selling soon.

Just a hunch.

Cause Sheridan/Amsurg/Envision brought the other huge group in Arizona a couple of years ago.

I just can't believe he forgot to mention Dr. Isabella Herb and all her work at Rush University started long before the first school of nurse aneshtesia popped up!

 

[GA8314]

This is simply a matter of leadership. ACT practices do not have to be sell outs. There are ways.