So, I finally got to shadow an anesthesiologist, and I must say...

[Planktonmd]

Please tell me what institution this is so I can knock it off my list. Training residents under a CRNAs supervision is a farce and slap in the face. If it was a med student on an elective I can understand but a resident? Please, this is just plain bs or your program is VERY poor.

Some places used to pair CA1 residents with CRNA's in the first 2 months or so untill they are more comfortable with their surroundings, and this used to be during the days of attendings being able to supervise 4 residents at the same time. That's not the case anymore but some programs might still be doing it just to allow one attending to supervise more rooms.
It's all about medicare rules.

---

Members don't see this ad.

 

[The_Sensei]

During my surgery rotations, I would say at least half of cases I saw were done by CRNAs, and CRNAs actually taught and supervised anesthesiology residents at my institution. The attending anesthesiologist would just quickly stop by the OR once or twice during the case and asked if everything was OK.

CRNAs appear to be very knowledgeable and have good bedside manner; they taught residents and me pretty well. From what I have seen, they receive equal respect from patients and surgeons as their MDA colleagues. Everybody happily works in team and no one looks down on anybody.

Truly a disgrace. During my residency, the only thing I learned from CRNAs was......um, NOTHING!

 

[VolatileAgent]

Truly a disgrace. During my residency, the only thing I learned from CRNAs was......um, NOTHING!

ditto.

 

[MacGyver]

I too have seen CRNAs training residents..... this is not an isolated incident, and its a damning indictment of hte profession.

Tell your program directors to quit selling your future out. You want somebody to blame, start by looking at your PDs and other greedy ass MDA bastards who werent happy pulling in 300k so they went and hired CRNAs to they could tack on an extra 75k per year.

CRNAs wouldnt have a leg to stand on if it werent for these MDA money ****** who werent happy with their 300k so they had to ***** out your profession to outsiders.

I want the names of these PDs who use CRNAs to train residents. Their programs should be disgraced, their program reputations should be destroyed. Everybody fess up right now. I WANT THEIR ****ING NAMES!

 

[fakin' the funk]

I want the names of these PDs who use CRNAs to train residents. Their programs should be disgraced, their program reputations should be destroyed. Everybody fess up right now. I WANT THEIR ****ING NAMES!

 

[Noyac]

I agree. These programs should be identified.

There are a few PD's on this site I'm sure. If their programs are doing this and they see that it is being broadcasted here, it should at least make them think about it.

 

[toughlife]

I'm a resident. I respect the CRNAs and SRNAs at my institution, but I don't consider them the professional equals to the MD/DO attendings and residents.

I have no studies to cite here, just personal experience.

Residents are never paired with CRNAs at my institution, so I never see them in the OR, unless I take over a case at the end of a day when I'm on call. I frequently find myself asking myself just WTF they were thinking.

But here's what I've observed though during my time in the PACU. Patients dropped off by CRNAs and SRNAs consistently have far more difficulties with hypertension, tachycardia, poor pain control, big hits of Dilaudid that peak after they get to the PACU, cookie-cutter post op orders. They just seem to be sloppier and less precise than the anesthesiologists and residents.

Are the outcomes for their patients worse, in terms of deaths or other sentinel events? Not that I can see. Are their patients' operative experiences less smooth? Frequently.

I wish I'd kept track of # of patients delivered by CRNAs/anesthesiologists vs. # of times I was paged to manage some postop issue by the PACU staff.

I strive to produce a nice anesthetic every time. It's an expectation from my staff every time I take a patient to the OR. Smooth induction, uneventful case, calm comfortable emergence, comfortable transition in recovery. From my limited PACU window of observation it just seems that that happens a lot less often with a CRNA.

Maybe this is all atypical, and the CRNAs at my hospital just suck. I am a young grasshopper yet, but there seems to be more to the practice of anesthesia than avoiding sentinel events, which is all the studies comparing CRNAs to anesthesiologists seem to look at.

I've seem this as well. I have even had the PACU nurses complain about certain CRNAs and how unstable their patients are brought to PACU.

 

[joshmir]

--------------------------------------------------------------------------------

>I agree. These programs should be identified.

>There are a few PD's on this site I'm sure. If their programs are doing this and they see that it is being >broadcasted here, it should at least make them think about it.


It should maybe be kept in mind that these progrmas may need SRNAs/CRNAs to make their finances work/fund research/etc. The Medicare teaching rule may help offset this, but with general medicare cuts coming down the road...

A while back UTSW posted that he was talking with leaders in academic programs in texas that have srna training programs, and they were ignorant of the AANA's lobbying efforts *specifically against* the Medicare teaching rule (the AANA's forum indicates that the reason is because they think it will unfairly redistribute some of the money pot away from CRNAs/SRNAs...) ANy update UT? One of the proposals he had was to charge a higher fee from the CRNA/SRNA schools to train them...

Here's the problem I wrestle with...the CRNAs I've met have all been great people...in my head I have trouble associating them with the AANA/militant-CRNA-national-lobby. it may be more useful to put pressure on SRNA/CRNA *schools* to put pressure on this militant lobby to bring about change. One way to do this seems to be charge them more money to train SRNAs in the hospital *tied explicitly to the message that they are being charged higher fees in response to the national militant lobby*. that gets away from punishing individuals, whom some of us enjoy working with.

also, anybody understand the issues surrounding why a large academic residency program would want to train CRNAs vs AAs? anyone know the cost/benefit?



What do you guys think of the proposal that together, we should all be *on message* that:

-ASAPAC contributions, the hiring/training of AAs, and leadership at large academic anesthesia residencies are the fulcrums for change

 

[Good Mountain]

Speaking of that, in certain third world countries they train highschool or even middle school drop outs to do menial/repetative hospital work that usually takes a bachelors or is done by doctors. Maybe they'll be replaced soon too.

Im from a "developing country" and let me say that there is not such a thing as a nurse performing anesthesia. Anesthesia is the most competitive residence in my country. There is a 6% of chance of entering in the anesthesia residence for a graduated physician. The problem that you have in the US is the lack of physicians. That leads to psicologist, optometrists, CRNAs and podiatrist to perform activities that a Doctor should do. I heard in other formus that in some states they are discussing the posibility of allowing optometrist to perform minor eye surgeries or even refractive surgeries. All this scenarios are incredible! Nurses performing anesthesias?

My questions are the following:

Surgeons do not care if they have a CRNA or an Anesthesiologist in their OR? I would if I where making the surgery.

What about malpractice insurrances? An insurrance company covers a nurse to perform a physicians job?

How long is the CRNAs carrer?? I mean, you have to handle physiology, pharmacology, ECG, Intensive Care, Anatomy, and quite a lot of disciplines

How much does a CRNA make? Maybe its just a question of saving money.


Note: I do not intend to be disrispectful to CRNAs, if it sounded that way, then pardon me. I just want to understand the situation.

 

[2ndyear]

I'll preface by stating I am an MD anesthesia resident:

Surgeons do not care if they have a CRNA or an Anesthesiologist in their OR? I would if I where making the surgery.
- Yes many don't care, or it's all they have where they practice, or in many situations it's a team practice where there are MD's available or involved in the case.

What about malpractice insurrances? An insurrance company covers a nurse to perform a physicians job?
- Like it or not, anesthesia is pretty safe, and it's not only a physicians job in the US. It started out in the US with ether that was a fairly safe drug. Med students, interns, and nurses all gave ether so surgeons could operate. So it never really started out as a physician specialty in the US. This is in contrast to England where chloroform was used and required more skill, physicians became the standard for anesthesia and there you go. If CRNA's were actively killing people then they would be tough to insure. That being said, it's a pretty self selecting group. These aren't you're basic associate degree med-surg nurses. All have bachelors degrees, ICU experience, supervised clinicals, and it's not easy to be accepted to CRNA school.

How long is the CRNAs carrer?? I mean, you have to handle physiology, pharmacology, ECG, Intensive Care, Anatomy, and quite a lot of disciplines
-Bachelors degree plus at least 1 year of ICU experience, then a roughly 2 year program of mixed classroom and clinical. Is it medical school? No.


How much does a CRNA make? Maybe its just a question of saving money.
-Say about a half to one-third as much as an MD, but with the potential for just as much. There are hospitals with only CRNA's providing anesthesia and they bill just like an MD.


Note: I do not intend to be disrispectful to CRNAs, if it sounded that way, then pardon me. I just want to understand the situation.[/QUOTE]

 

[threepeas]

1. The question is not whether some high speed CRNAs can practice autonomously, the question is can all new CRNA graduates practice independently? the answer is a resounding no. all new anesthesiologists are expected to practice independently though. the measure of one's training is in what your new grads can do, especially if there isnt any post graduate enhanced credentialing available.
2. CRNA programs do not use dentist or surgeons to supervise their training. Why would a CRNA want to practice their trade with these folks as supervising physicians. the CRNA knows more than they do, so how can they be truly supervising to the betterment of the patient? if CRNAs are to be supervised it make more sense to use someone who has more training in the field of anesthesiology such as MD trained anesthesiologist.
3. regardless of what a governor or legislative body passes into law patients expect a physician trained in the field involved specific to their care to participate on some level. CRNAs supervised by doctors not trained in anesthesia is somewhat deceitful in my opinion. the public needs to hold legislators accountable for not protecting their standard of care. so eventhough a state's law may allow CRNAs to practice under a non anesthesiologist doctor doesnt mean it is right and what's best for the patient. lawmakers make decisions for the wrong reasons all the time and CRNAs should not be pounding their chest in victory based on a law/policy made by non health care professionals who know nothing about the practice of medicine.

 

[utmey07]

I think we can only blame ourselves as MD's for not advocating for ourselves. I have heard too many times on residency interviews from PD's and chair's saying that the majority of our profession doesn't care to help with lobbying or advocation. Until that changes the group (not us MD's) with the better national organization, larger manpower, and 'cost effectiveness' will continue to gain ground and rightfully so; it appears they want it more.

Also to address the initial thread: wait until you've gone through most of medical school, then do a rotation in anesthesia. Things will change quite a bit. I used to want to be an FP...yikes...

 

[BIS]

1. The question is not whether some high speed CRNAs can practice autonomously, the question is can all new CRNA graduates practice independently? the answer is a resounding no. all new anesthesiologists are expected to practice independently though. the measure of one's training is in what your new grads can do, especially if there isnt any post graduate enhanced credentialing available.
2. CRNA programs do not use dentist or surgeons to supervise their training. Why would a CRNA want to practice their trade with these folks as supervising physicians. the CRNA knows more than they do, so how can they be truly supervising to the betterment of the patient? if CRNAs are to be supervised it make more sense to use someone who has more training in the field of anesthesiology such as MD trained anesthesiologist.
3. regardless of what a governor or legislative body passes into law patients expect a physician trained in the field involved specific to their care to participate on some level. CRNAs supervised by doctors not trained in anesthesia is somewhat deceitful in my opinion. the public needs to hold legislators accountable for not protecting their standard of care. so eventhough a state's law may allow CRNAs to practice under a non anesthesiologist doctor doesnt mean it is right and what's best for the patient. lawmakers make decisions for the wrong reasons all the time and CRNAs should not be pounding their chest in victory based on a law/policy made by non health care professionals who know nothing about the practice of medicine.

CRNA's do not need Anesthesiologist Supervision specifically in any state. Supervision is a CMS (billing ) issue that is confusing.

 

[matt1234321]

I think we can only blame ourselves as MD's for not advocating for ourselves. I have heard too many times on residency interviews from PD's and chair's saying that the majority of our profession doesn't care to help with lobbying or advocation. Until that changes the group (not us MD's) with the better national organization, larger manpower, and 'cost effectiveness' will continue to gain ground and rightfully so; it appears they want it more.

Also to address the initial thread: wait until you've gone through most of medical school, then do a rotation in anesthesia. Things will change quite a bit. I used to want to be an FP...yikes...

AND 20 dollars a year won't cut it.

HOW BOUT $100 a week from every anesthesiologist. You will see results!!!!!!

 

[curious1]

this thread is hilarious... my dad is an anesthesiologist... before he hired CRNAs he made 400k now he is at 600k... the CRNAs make close to 200k! and guess what, the CRNAs all whine all the time. they never want to take night shifts. they give you a funny look if you ask them to work more than 60 hours a week. this is why every hospital that has tried a hospital-run CRNA service has failed miserably. some nose and boob joint out in california doesn't count for much. i don't know how much you know about health care, but hospitals within a city do have to compete with each other, for surgeons... and a big draw is stable, high quality anesthesia. personally i'm a fan of surgery and i couldn't stand anesthesia but there's a huge shortage of them and that means they get paid.

 

[VolatileAgent]

this thread is hilarious... my dad is an anesthesiologist... before he hired CRNAs he made 400k now he is at 600k... the CRNAs make close to 200k! and guess what, the CRNAs all whine all the time. they never want to take night shifts. they give you a funny look if you ask them to work more than 60 hours a week. this is why every hospital that has tried a hospital-run CRNA service has failed miserably. some nose and boob joint out in california doesn't count for much. i don't know how much you know about health care, but hospitals within a city do have to compete with each other, for surgeons... and a big draw is stable, high quality anesthesia. personally i'm a fan of surgery and i couldn't stand anesthesia but there's a huge shortage of them and that means they get paid.

 

[Jsad]

Ibl

 

[Stimulate]

A couple of thoughts:
1) If a CRNA is practicing under the supervision of a surgeon, dentist, podiatrist, and if there is a bad outcome the PHYSICIAN is ultimately responsible. This is why the malpractice premiums for "independent" CRNAs has not risen to the level of anesthesiologist premiums. Some would wonder why the PHYSICIAN would take that risk. At least with an anesthesiologist participating, a bad outcome could potentially be shared by each. Also, this type of a situation puts in jeopardy the CRNA's objective judgement because they have to follow the orders of their supervising PHYSICIAN. For example, what happens when you are doing a MAC case and the surgeon tells you, the nurse, to deepen the patient with more propofol? Are you not obligated to do as they order? If you are a CRNA who doesn't follow the orders then the surgeon will likely replace you because they will want a CRNA who knows how to listen. An anesthesiologist will be better positioned to disagree with the surgeon and be a patient advocate because there is no supervisory relationship between the surgeon and him/her. The anesthesiologist is capable of independent practice, and that principle is defined from the beginning.
2) So why do surgeons take this risk of supervising the practice of anesthesia? Well, because there is some financial incentive to do so. The rules regarding kickbacks are setforth in "Stark" laws. Basically they allow for ambulatory surgery centers to compensate their referring surgeons, but not on a volume-based or per-case basis. The compensation has to be more of an annual stipend paid to the PHYSICIAN by the Surgicenter. So, perhaps with the CRNA-owned and operated ASC in California, the surgeons may be getting larger stipends than if they utilized a hospital or physician-owned ASC. Maybe it is just closer to their office. Who knows.
3) At our institution the CRNAs/SRNAs cannot write post-operative pain and nausea orders because this is the practice of medicine. As a result of this their patients suffer when compared to my patients because when a CRNA's patient has pain, the PACU nurse must page a PHYSICIAN, and wait for him/her to respond prior to that patient receiving any analgesia.
4) I find it interesting that "Conflicted" states that he doesn't have the knowledge or training to provide care for intensive care patients but that he does have the full knowledge base to take care of patients in the OR. Many of the complex physiology and pharmacologic management principles are similar. I don't think you can draw a line between the two and say that you have the knowledge for one and not the other. Maybe "conflicted" doesn't understand that because in order to examine this issue, you need to possess that level of knowledge to begin with.
5) Let's say hypothetically that in the future CRNAs and MD anesthesiologists become totally equivalent. In this scenario, patients and surgeons would have a choice between nurse and physician provided anesthetic care. Who do you think people will choose? I have many patients who request no CRNAs be involved in their care (with the exception of friends of CRNAs who always request their friends which is understandable). I am very comfortable with competing with CRNAs for "work" because I believe that I provide a better service. If the patients and their insurance carriers are paying the same price, the physician will have no difficulty finding work.

 

[curious1]

Stimulate makes more good points...

You can request that your care be provided 100% by anesthesiolgists and they are required to provide that for you... but few people know this... it wouldn't take much of a public campaign to get everyone saying "no CRNAs please".

 

[Noyac]

Stimulate makes more good points...

You can request that your care be provided 100% by anesthesiolgists and they are required to provide that for you... but few people know this... it wouldn't take much of a public campaign to get everyone saying "no CRNAs please".

All this would take is a little advertisement. But instead the ASA continues to watch the AANA advertise, all while accomplishing nothing in Washington.

 

[salmonella]

All this would take is a little advertisement. But instead the ASA continues to watch the AANA advertise, all while accomplishing nothing in Washington.

It's interesting that when patients go to their PCP, a lot of them would ask to be seen by MDs rather than PA/NPs. But when it comes to anesthesia, it seems like patients don't care as much. Believe it or not, some patients that I talked to didn't even know there were such thing as anesthesiologist...they thought nurses routinely put people to sleep for surgery.

 

[Noyac]

It's interesting that when patients go to their PCP, a lot of them would ask to be seen by MDs rather than PA/NPs. But when it comes to anesthesia, it seems like patients don't care as much. Believe it or not, some patients that I talked to didn't even know there were such thing as anesthesiologist...they thought nurses routinely put people to sleep for surgery.

Thats funny, my pts have asked more about nurses for anesthesia. They have heard some of the advertisement and were confused because they had no idea that a nurse could be giving their anesthetic. They have also expressed concern about this. The pt population is a bit different here though. They are more educated as a whole and are very involved in their care.

 

[Conflicted]

Come now Noy.

You say this:

They have also expressed concern about this. The pt population is a bit different here though. They are more educated as a whole and are very involved in their care.

But since its been proven that CRNAs and Anesthesiologists have the exact same saftey rate individually and its only better when working togeather, would they be LESS educated?

 

[cfdavid]

It's interesting that when patients go to their PCP, a lot of them would ask to be seen by MDs rather than PA/NPs. But when it comes to anesthesia, it seems like patients don't care as much. Believe it or not, some patients that I talked to didn't even know there were such thing as anesthesiologist...they thought nurses routinely put people to sleep for surgery.

No, I don't believe it.

 

[salmonella]

No, I don't believe it.

May be it's just the patient population I am dealing with: most of them are non English speaking, have no insurance, and medically indigent.

 

[cloud9]

But since its been proven that CRNAs and Anesthesiologists have the exact same saftey rate individually and its only better when working togeather, would they be LESS educated?

What does the education level of the patient population have to do with the safety rate of CRNA vs MD?

 

[VolatileAgent]

But since its been proven that CRNAs and Anesthesiologists have the exact same saftey rate individually...

huh? where has this been proven? and, don't go quoting the flawed pine study again... we already covered that way back on this thread.

all that's been proven is that you think if you keep saying that over and over again, stupid people (like yourself) will start to believe it.

 

[MacGyver]

I'm still waiting for the names of the gas residency programs that have sold their souls to CRNAs.

Again, I want their ****ing names. We should shame these PDs into public humiliation. Force them to take FMGs and watch their rep plummet.

 

[Conflicted]

*sigh*

I know, I know, if it dosent fit your personal opinions then it MUST be flawed eh? Of course, there has not been a single study near the scope of the pine to refute it (not for lack of trying). I think it is YOU who are trying to convince yourself of something.

Sadly, the only way you can argue is by attacking me. What an excellent reflection on your colleagues you are, they should be ashamed of you.

P.S. Dont bother responding, i wont reply to your drivel.

huh? where has this been proven? and, don't go quoting the flawed pine study again... we already covered that way back on this thread.

all that's been proven is that you think if you keep saying that over and over again, stupid people (like yourself) will start to believe it.

 

[curious1]

All this would take is a little advertisement. But instead the ASA continues to watch the AANA advertise, all while accomplishing nothing in Washington.

this would be like declaring open war on CRNAs... i'm all for it, but, it's not something to be done casually, and once it's done, it's hard to undo. if we see a repeat of the early 90s and anesthesiologists start getting fired, then i think the ASA's attitude will change.

 

[salmonella]

this would be like declaring open war on CRNAs... i'm all for it, but, it's not something to be done casually, and once it's done, it's hard to undo. if we see a repeat of the early 90s and anesthesiologists start getting fired, then i think the ASA's attitude will change.

I guess I'm confused about the role of CRNAs: Are they allowed to do procedures like swan-ganz, TEE, laryngoscopy, awake intubation? These are pretty hardcore procedures that I thought only MDs could do and interpret the results. How about anesthetizing major trauma patients with h/o multiple medical problems? CRNAs can handle these patients independently too? If CRNAs are able to do all these safely at much cheaper salary, then I think MDAs should be concerned about job security...

 

[UTSouthwestern]

This has been an interesting thread and one that I will keep an eye on. I haven't posted on this thread because to be honest, I've been busier than ever with my group's practice, much less the Christmas holiday.

For those of you in Dallas, or surrounding communities, I am arranging a dinner meeting with Manuel Bonilla from the office of government and legal affairs of the ASA. He will give a small presentation of the issues facing anesthesiologists in the legal arena and then I have told him that it will be open season on him (I'm paying for him to fly in and stay here, so I should be able to beat on him a little as well). This will be an opportunity for us to question the leadership of our organization as well as to emphasize our goals for the ASA as donating members of the ASA.

For those interested and able to attend (I will shoot for May or early June to avoid orals and echo boards), I will cover your dinner costs. For those not able but wanting to attend, PM me any and all questions you might have.


Activism and funding is the key to ensuring that our profession maintains its position in the medical, legal, and public communities. The fact of the matter is that we have not as a whole been active as a specialty in advocating the strengths and benefits of our field. As many of us have noted, our competition has no qualms about advertising and our lack thereof has made our professional visibility limited.

Many patients are unaware of the choices they have. Many would seek to keep it that way or minimize differences within the field. Our best advertisement has unfortunately been through the misfortunes of patients unaware of their choices and situation.

It will be up to us to ensure the future of our specialty.

 

[VentdependenT]

This has been an interesting thread and one that I will keep an eye on. I haven't posted on this thread because to be honest, I've been busier than ever with my group's practice, much less the Christmas holiday.

For those of you in Dallas, or surrounding communities, I am arranging a dinner meeting with Manuel Bonilla from the office of government and legal affairs of the ASA. He will give a small presentation of the issues facing anesthesiologists in the legal arena and then I have told him that it will be open season on him (I'm paying for him to fly in and stay here, so I should be able to beat on him a little as well). This will be an opportunity for us to question the leadership of our organization as well as to emphasize our goals for the ASA as donating members of the ASA.

For those interested and able to attend (I will shoot for May or early June to avoid orals and echo boards), I will cover your dinner costs. For those not able but wanting to attend, PM me any and all questions you might have.


Activism and funding is the key to ensuring that our profession maintains its position in the medical, legal, and public communities. The fact of the matter is that we have not as a whole been active as a specialty in advocating the strengths and benefits of our field. As many of us have noted, our competition has no qualms about advertising and our lack thereof has made our professional visibility limited.

Many patients are unaware of the choices they have. Many would seek to keep it that way or minimize differences within the field. Our best advertisement has unfortunately been through the misfortunes of patients unaware of their choices and situation.

It will be up to us to ensure the future of our specialty.

tell me where to sign up to help out. im in.

 

[2ndyear]

I guess I'm confused about the role of CRNAs: Are they allowed to do procedures like swan-ganz, TEE, laryngoscopy, awake intubation? These are pretty hardcore procedures that I thought only MDs could do and interpret the results. How about anesthetizing major trauma patients with h/o multiple medical problems? CRNAs can handle these patients independently too? If CRNAs are able to do all these safely at much cheaper salary, then I think MDAs should be concerned about job security...

Yes, yes, yes, and yes. CRNA's definately float swans and interpret the results, laryngoscopy goes without saying, awake intubations- another yes. As for TEE they can interpret the images just as any MD can who is not echo certified. As I understand it as a resident, this means they just can't bill for it. Again, major traumas with multiple medical problems is a yes. The real answer lies in how often this happens independently. A major trauma center having only CRNA's would be pretty rare and the same thing goes for hospitals that do hearts. I'm not saying that there aren't a few centers out there that do hearts and trauma with an all CRNA staff, because I'm sure there are, but the number is low.

As for job security I'm not too worried. Most practices that do these bigger cases are in a care team format. It's not like there are CRNA's running around trying to buy out anesthesia groups because they're willing to work for less money. Care team practices offer a lot in terms of scheduling, hours, and stability. Those that want more or total autonomy can go elsewhere and then have the burden of more call, more responsibility and more liability.

You can make the midlevel argument for just about any specialty outside of surgery, pathology and radiology. NP's can open up their own primary care offices, staff the NICU and ICU, do cosmetic procedures, deliver babies, and so on. Yet despite all of this the job market is still pretty good for MD's as a whole. Not a lot of unemployment going on.

 

[OffPiste]

First off, Im an anesthesia resident at a program that also has an excellent CRNA program. Let me say that I have no problems with CRNA's. Most that I work with seem to be diligent and knowledgeable, and get me out of the OR for lectures, conference, lunch, etc. Although sometimes they make protocol based decisions without being aware of pathophysiologic consequences. I tend to think that as future anesthesiologists, we are lucky, in that the nurses that we deal with on a daily basis are clearly the best and brightest of the nursing profession. This certainly makes my life easier.

However, in regard to CRNA's floating swans, interpreting TEE, and doing difficult awake fiberoptics, I call BS, BS BS. These are elegant and risky procedures fraught with medicolegal liabilty. Any difficult awakes are always done by anesthesiologists or residents. Swans, with the rarity of these nowadays, I would be willing to bet over 99% of all CRNA's will never touch this, and would never even consider floating a swan without an attending standing over them walking through the procedure. Furthermore, I have never seen a CRNA touch the Echo probe, much less, "interpret" the results. CRNA's are not associated with regional techniques in any way at my program either. And while they may sit the stool in a cardiac room, they certainly do not plan the anesthetic, or undergo induction/emergence alone. My program is considered to have one of the best CRNA programs in the country. So I will go on confident in my future and skills, and will enjoy working with my CRNA colleauges. Because we all know when the rubber hits the road and proverbial feces hits the fan, guess who gets the call.

I'm not trying to perpetuate another MD vs. CRNA thread, but when pure BS is issued forth, I gotta call a brotha out.

 

[toughlife]

we need to do MORE!!!!

Look at bottom table and tell me all of you are doing your best to contribute? This is a shame. Stop thinking someone else will do it for you, and send your contribution.

http://www.asahq.org/Newsletters/2006/12-06/becker12_06.html

 

[toughlife]

This has been an interesting thread and one that I will keep an eye on. I haven't posted on this thread because to be honest, I've been busier than ever with my group's practice, much less the Christmas holiday.

For those of you in Dallas, or surrounding communities, I am arranging a dinner meeting with Manuel Bonilla from the office of government and legal affairs of the ASA. He will give a small presentation of the issues facing anesthesiologists in the legal arena and then I have told him that it will be open season on him (I'm paying for him to fly in and stay here, so I should be able to beat on him a little as well). This will be an opportunity for us to question the leadership of our organization as well as to emphasize our goals for the ASA as donating members of the ASA.

For those interested and able to attend (I will shoot for May or early June to avoid orals and echo boards), I will cover your dinner costs. For those not able but wanting to attend, PM me any and all questions you might have.


Activism and funding is the key to ensuring that our profession maintains its position in the medical, legal, and public communities. The fact of the matter is that we have not as a whole been active as a specialty in advocating the strengths and benefits of our field. As many of us have noted, our competition has no qualms about advertising and our lack thereof has made our professional visibility limited.

Many patients are unaware of the choices they have. Many would seek to keep it that way or minimize differences within the field. Our best advertisement has unfortunately been through the misfortunes of patients unaware of their choices and situation.

It will be up to us to ensure the future of our specialty.

I'd be happy to attend if notified of date in advance.

 

[VolatileAgent]

I know, I know, if it dosent fit your personal opinions then it MUST be flawed eh?

you see, this is your problem. this has nothing to do with personal opinions or feelings or what i think, which is often what most nurses base their decisions on, and everything to do with lack of data to support your statement: that it is proven that there is no difference in crna's and anesthesiologists safety performance individually. hogwash. both the pine and silber studies were never designed to make such a distinction. futhermore, anesthesiologists are involved in over 90% of all anesthetics administered on a daily basis. yet, you will spuriously hear that crna's give 65% of all anesthetics, which doesn't tell the whole story. so, it becomes very hard to discern ANYTHING meaningful at the margins, especially when you are dealing with such a small percentage of crna's who aren't directly supervised by an anesthesiologist and none of whom aren't supervised by a doctor at all.

so, yes, the data supports that a team environment, with an anesthesiologist directing care, is superior. no one is arguing that. what you are then trying to conclude from that, based on limited data using a crappy study (pine) which only looked at bread-and-butter cases, is that crna's and anesthesiologists are equal and therefore should have equal access to independent practice, which neither study even remotely attempts to argue and, in fact, suggests the opposite (see beginning of this paragraph, and read that a few times until it sinks in). so, the reality is that the data you're touting actually supports continuing things exactly the way are right now. it in no way supports giving crna's independent practice rights.

furthermore, this does not speak to the nuance in giving an anesthetic. the "feel" one develops, using a broad, deep understanding of medicine and medical knowledge, that lends itself to giving a better anesthetic. i've taken over cases from seasoned crna's and seriously thought to myself "what the hell were they thinking?" not that they were doing anything "unsafe" and that the patient was going to have a bad outcome from the case; just that the anesthetic they were giving was cookie-cutter and unimaginative. so, the entire premise that the pine study (and silber, for that matter) is not even an appropriate yardstick to measure the differences between our superior medical training and your (what is essentially) protocol practices.

utsouthwestern: i'm all ears. the situation we have created is one of our own doing. contrary to what some people believe, the candidates i've seen on the interview trail this year, our future leaders, are not "slackers" looking for a cush lifestyle. they are people at the top of their class with stellar board scores and records of achievement. the future of our profession looks bright. i'm hoping that there is a growing activisim as these bright up-and-comers get into the field.

as far as contributing, i have the asapac record of contributions and i was disappointed to see how few people i knew were in there. we are not politically active because of a lot of the sentiment you see in posters like militarymd, the "fend for yourself and f**k everyone else" mentality. he is representative of the types that are out there in private practice, and until we can get past that mentality and be more like the aana in our efforts to promote our profession, then we are going to suffer the slings and arrows of the "men's health" articles and other garbage that the media protrays about our profession.

the fact is, most people go to the hospital believing that a physician is giving them their anesthetic. most would be shocked to learn that this was not always the case 100% of the time. the problem is, there aren't enough of us out there right now to fill the demand if we were to start a publicity campaign about the dirty tricks the naughty nurses at the aana engage in. bottom line is that we need to increase our political presence and continue to lobby and advocate for ourselves at the state and national level. pretty soon there are going to be a plethora of crna's for not enough jobs, and then they'll start in-fighting. when that happens, this current "problem" we have will take care of itself.

 

[militarymd]

give me a break....

 

[VolatileAgent]

give me a break....

oh, i'd love to.

 

[militarymd]

oh, i'd love to.

I thought you were staying in academia......


where you can:

1) order unnecessary tests
2) delay/cancel cases
3) be and act like a "doctor"
4) not worry about competition
5) look down your nose at guys like me and other non-physicians who provide anesthesia services

 

[Conflicted]

BWhahhahahahah

Now there is a physician I would work in a ACT practice with ANY DAY.

I thought you were staying in academia......


where you can:

1) order unnecessary tests
2) delay/cancel cases
3) be and act like a "doctor"
4) not worry about competition
5) look down your nose at guys like me and other non-physicians who provide anesthesia services

 

[mille125]

Very interesting discussion. Conflicted, I am not trying to pick on your with this question. Maybe you can answer it and maybe you cant. I finished an anesthesia residency but now practice 100% pain management. I have had a chance to talk to many CRNA's/SRNA's. First of all most do an excellent job. It is my feeling that the vast majority are very happy with practicing in the anesthesia care team. There are a few that want nationwide independent practice. Most in the latter group say that independent practice would provide for more anesthesia providers especially for the underserved. My question is this: "Why is your society opposed to anesthesia assistants (AA's)". I think that they would also help with this mission.


Everyone on this forum seems to like quoting studies. The bottom line is the the practice of anesthesiology is very safe. You would need to have a very very large study to show any difference in outcomes.

 

[mille125]

It isn't at all what I thought it was, and I'm fairly dissapointed. I used to think the anesthesiologists just sat there with their hand on a dial and it was sort of a fluff job. I tried to get myself away from that sort of thinking. "The CRNAs are the ones that do that... Anesthesiologists have to interview patients, choose which methods and drugs to use, etc." And I believed all that for a pretty long time. The anesthesiolgists are running from OR to OR putting people under and waking them up. Running codes and saving lives.

I'm really pretty depressed about it. In the reality of what I saw, the CRNAs did almost all of the work to speak of. They intubated, controlled the drugs, monitored, and then woke them up. The guy I shadowed just sort of supervised. Sure they guy was smart as hell and knew his ****. During the interviews and pre-op he could assess all the lab results and nurse's notes in a matter of minutes. "Platelets are low, RBC are low, psychosis dilirium, coughing up green mucus. He probably has pneumonia. We listen to his lungs. Yep, pneumonia. Send him to pulmonary to get him cleaned up, we can't operate." But really after that, there was a lot of sitting around.

As far as the anesthesia part went, he had me watch 2-3 CRNA's intubate: an obese, a ped, and an elderly. I asked some questions about the drugs, he answered. I asked more about intubation and he showed me some videos and went over some of the techniques, how to know you're in the right tube, etc. Other than that, we spent a lot of time in the anesthesiologist's lounge. There were 2 anesthesiologists that day and a lot of times both were in that lounge. After a while he just took me from OR to OR to watch different surgeries and called it a day.

I hate to say it, but the whole day I was there, he really didn't do anything. I know it's important for him to be around in case something comes up that a CRNA can't handle, but really there was a lot of standing around when there wasn't anything to do.

The reason I bring this all up is because I've always wanted to do anesthesiology. People have tried to talk me out of it, but I never listened. I hated watching the CRNAs suffle papers periodically just to appear busy (it was obvious. I have a useless job right now and I occasionaly get asked why I even need to be there. Which honestly, sometimes I wonder myself.) I really want a job where I feel I have a purpose, and the team would be much worse off without me. I want to be indespensable. Sitting around in the lounge for 20-30mins at a time with the doctor I was shadowing just made me think a lot. I watched a laproscopic gastric bypass. I was talking to the GI surgeon afterwards and asked if today (yesterday) was a slow day by most standars. "No, I've been going at it since 4am. I won't get to see the outside of the operating area for another 8 hours."

I totally appreciate the opportunity to shadow a doctor, but I guess this just sort of opened my eyes. I know his son, and he says that his dad goes crazy not having anything to do. He's actually gotten in trouble for picking up a mop and cleaning up the anesthesiology office. It sounds like a nice lifestyle, but I just don't know if I can do that. Seeing teams of surgeons working together to finish a case and seeing the CRNA off by himself next to his machine... The anesthesiologist only making a brief appearance before and after the surgeries, and then only to supervise.

Maybe this isn't the normal case at all (be sure to correct me if I'm wrong) but after what I've seen that day and read what I have on this forum about anthesiologist groups and a lot of general attitudes, anesthesiology no longer has any appeal to me. Despite the sacrifices needed, I really want to do surgery now.

Feel free to discuss. Sorry this post got so long.

Pinch,

To comment on your initial post (which seemed like many moons ago). I would say that impression of anesthesiology was an active one. In most situation you will have a supervisory role over CRNA's and or residents. There are a MD only practices in the west. Many physicians who like during their own cases may gravitate to these practices. I would suggest getting more experiences before crossing anesthesiology off your list. There are usually many electives that serve this purpose. Good luck.

 

[VolatileAgent]

1) order unnecessary tests
2) delay/cancel cases
3) be and act like a "doctor"
4) not worry about competition
5) look down your nose at guys like me and other non-physicians who provide anesthesia services

1) i've never ordered an unnecessary test
2) i've never delayed/canceled a case; i've brought up issues that have resulted in surgeons canceling cases... rarely
3) i am a doctor; apparently you've forgotten that you are one as well - if you want to be and act like a technician, fine. maybe you should've saved some coin and gone to nursing school instead.
4) huh? i'm going into private practice. i'm less worried about mom-and-pop niche practices (like yours) than i am about large anesthesia management companies who are "wal-marting" our profession. so, you keep kissing the important asses and browning your nose with the higher-ups at your hospital. see how far that gets you when napa (or the like) comes to your neighborhood. i'll give you a hint: i'll be having the last laugh (witness jetproppilot, but i'm not laughing at him 'cuz underneath it all he's a cool dude).
5) again, remind me why your practice doesn't hire crna's...

 

[Conflicted]

Hi mille

Personally, I dont have an interest in indy practice. I like working in the ACT practice and i enjoy the collegiate relationship which exists in the practice (contrary to how some here act).

Those CRNAs who are independent practice work in undeserved areas. These are places that anesthesiologists frankly, dont want to live. However, contrary to the propaganda oft spouted, without them many rural ORs would shut down and, so too would the hospital.

AAs dont solve the issue in the indy/rural practices as they are not allowed to work without a supervising anesthesiologist. As for why the association is against AAs, well i would not presume to speak for them. Personally, i see it as a political/economic issue. The more anesthesia people you add to the pot the lower the wages will get. Also, I believe many see AAs as the "Final solution" the ASA has come up with to the "CRNA Question". If you create your own grp of assistants who can never break away from you then you have 100% control over them.

But really, thats just my opinion. jwk may be able to add more insight than I on AAs and the politics surrounding it. I dont get involved with it at all.

Very interesting discussion. Conflicted, I am not trying to pick on your with this question. Maybe you can answer it and maybe you cant. I finished an anesthesia residency but now practice 100% pain management. I have had a chance to talk to many CRNA's/SRNA's. First of all most do an excellent job. It is my feeling that the vast majority are very happy with practicing in the anesthesia care team. There are a few that want nationwide independent practice. Most in the latter group say that independent practice would provide for more anesthesia providers especially for the underserved. My question is this: "Why is your society opposed to anesthesia assistants (AA's)". I think that they would also help with this mission.


Everyone on this forum seems to like quoting studies. The bottom line is the the practice of anesthesiology is very safe. You would need to have a very very large study to show any difference in outcomes.

 

[militarymd]

1) i've never ordered an unnecessary test
2) i've never delayed/canceled a case; i've brought up issues that have resulted in surgeons canceling cases... rarely
3) i am a doctor; apparently you've forgotten that you are one as well - if you want to be and act like a technician, fine. maybe you should've saved some coin and gone to nursing school instead.
4) huh? i'm going into private practice. i'm less worried about mom-and-pop niche practices (like yours) than i am about large anesthesia management companies who are "wal-marting" our profession. so, you keep kissing the important asses and browning your nose with the higher-ups at your hospital. see how far that gets you when napa (or the like) comes to your neighborhood. i'll give you a hint: i'll be having the last laugh (witness jetproppilot, but i'm not laughing at him 'cuz underneath it all he's a cool dude).
5) again, remind me why your practice doesn't hire crna's...

YOU are a freaking resident.

YOU dont' cancell cases......YOU don't approve cases....YOU do what your attending tells you to do.

UNLESS of course your residency program is one of those where attendings drink coffee and residents run amuck....

Laugh away.........keep laughing....laugh all you want, but when the sun sets, you are STILL JUST A RESIDENT....doing anesthesia (not practice medicine) on someone elses credit card.

 

[VolatileAgent]

still haven't answered...

5) again, remind me why your practice doesn't hire crna's...

iow (especially for you, conflicted), can anyone say hypocrite?

 

[VolatileAgent]

YOU are a freaking resident.

YOU dont' cancell cases......YOU don't approve cases....YOU do what your attending tells you to do.

UNLESS of course your residency program is one of those where attendings drink coffee and residents run amuck....

Laugh away.........keep laughing....laugh all you want, but when the sun sets, you are STILL JUST A RESIDENT....doing anesthesia (not practice medicine) on someone elses credit card.

if this is a self-reflection of the lack of autonomy, responsibility and decision-making ability you had as a resident, that really, REALLY explains a lot...

 

[militarymd]

if this is a self-reflection of the lack of autonomy, responsibility and decision-making ability you had as a resident, that really, REALLY explains a lot...

The GO/NO GO decision is one of very few medical decisions that are made for patients going to the OR......

If you are at a training program where one of the very few decisions are handed over to inexperienced trainees.......then we might as well just give it ALL up to non-physician providers.