Certified registered nurse anesthetists: out to replace MDs?

Dr Parks, It doesn’t surprise me your anesthesia “rotation” either as a medical student or resident neglected to inform you that nurses have been giving anesthesia a hell of a lot longer than physicians. The Mayo brothers preferred the vigilance of their nurse anesthetists. And if Minnesota is too far away for you, check the history of Ohio’s own Dr George Crile and his preference for nurse anesthetists. On the battlefields of France during World War I it was the NURSE teaching their European physician counterparts how it was done. Your assertion that anesthesia is something CRNA’s recently picked up secondary to the development of better monitoring is an affront to the rich history and legacy of many anesthetists. Lets hope the families of the two CRNA’s whose names are on the Vietnam Memorial miss your less than objective theory.

Comment by John Polechetti CRNA MS — September 7, 2010 @ 8:15 pm

The problem is that, while there is certainly overlap in the difficulty of the cases CRNAs and MDs cover, CRNAs are by-and-large not given the most difficult cases. By this I mean most cardiac surgery cases, most pediatric cases, most neurosurgery cases, and many other types of surgeries. To that effect, we can only effectively compare the outcomes of the cases that both CRNAs and MDs cover–what are generally considered the “easiest” cases. Of course, mortality in these cases will be comparable.

What we need to further delineate is whether there are other complications that we havent completely accounted for in the studies that have been done so far on this topic. And let’s be completely fair, the most recent studies have been SPONSORED by the American Association of Nurse Anesthetists, with the obvious unstated goal of SHOWING that there is no difference in care.

What we really need are completely unbiased eyes looking at the data. This is what we do NOT have, and until then, wouldn’t you rather have a physician watching over you in the most vulnerable and critical time of your life–during a surgical operation? Something to ponder.

Comment by RP — September 7, 2010 @ 9:35 pm

Mr. Polechetti,

Nurses may have been pushing drugs for the past 100 years, and there may be a handful of surgeons who prefer to work with nurses (so that they don’t have to deal with a perceived power struggle), but the advancement of anesthesia safety and science has been solely through physician endeavors. Reading the AANA’s journal is like reading a graduate level publication, at best.

And by the way, when the cardiac surgeon, the neurosurgeon, the pediatric surgeon (you get the point) has a problem, they don’t ask for another anesthetist. They ask for me. And who cares how long nurses have given sedation. Before all the monitors that physician scientists developed, patients were dying left and right from anesthesia.

Dr. Parks, interesting article. I do have to say I don’t practice through a check list method. I’m a physician, and the decision making process I learned through medical school and residency is my system.

Comment by Anesthesiologist — September 7, 2010 @ 11:08 pm

There is a perception in the minds of many as mentioned by some on this forum that CRNAs are not given tough cases but those are reserved for the anesthesiologists. I find that in our community history having worked at both the county hospital and a local community hospital as a solo anesthetist without anesthesiologist availability the division of who gets which patient is more based upon financial payer mix than difficulty of anesthetic. At our county hospital which was also the trauma center the CRNAs did all the anesthesia for the most extremely challenging cases from craniotomies to ruptured AAAs. All this was done with minimal input from whatever boderline anesthesiologist the county thought they could afford to be our supervisor. These MDs did their supervising from the sleep rooms. The qualified good MDs were and still are centered at the private hospital in the good part of town where all the insured patients get their care.

Comment by Robert Ford — September 8, 2010 @ 12:53 am

“These MDs did their supervising from the sleep rooms.”

Oh like right now while I’m up putting out fires (epidurals, central lines, talking to a cardiologist about a patient on for tomorrow), while FOUR anesthetists are in their sleep rooms. Any by the way, I work about 60 hours a week, and they work 36! Talk to someone who cares.

I supervise 3-4 rooms every day, all day long (including hearts with TEE, peds, neuro, major vascular). Just as far as pure clinical decision making, I solve more problems in a hour than an anesthetist does in a week.

Comment by Anesthesiologist — September 8, 2010 @ 4:18 am

Dr. Parks, just to enlighten you. The CRNA profession began when back in the civial war. WAY before physicians were anesthesia providers. Then in the early 1900′s when surgeons like yourself were performing cases, they wanted a nurse to monitor their patient during the procedure reducing mortalities. From this began the nurse anesthetist profession. MDs began gaining interest once the $$ started rolling in in the field of anesthesia. Ever ask yourself was are so many CRNAs serving in the military and on the battelfield vs MDs. The crna practice is very arbitrary. We are sfe during certain events but not for others. By the way, the acuity id quite high on the battlefield and we handel it without any problems!! When $$ is in the picture, the fight begins. Why are anesthesiologist the ONLY physicians who do not diagnosis? Isn’t that what a physician is trained to do? Diagnosis and treat? Is anesthesia really the practice of medicine?

Comment by Michael — September 8, 2010 @ 1:38 pm

Michael,

Your lack of understanding of the medical practice of perioperative care is exactly why physicians are needed in the perioperative setting. Anesthesia is not simply pushing some drugs, sticking a tube in the trachea, and watching a monitor. Those things, I agree, don’t require a physician. What does require a physician is planning and implementing anesthesia care related to the disease state of the patient and the surgical procedure. It includes postoperative care, managing and DIAGNOSING medical issues/emergencies that occur daily in the OR. Anesthesia care of the trauma patient has its own challenges, but from a pathophysiology standpoint, it is one of the least challenging components of anesthesia care.

It is scary to think there are nurse anesthetists who believe anesthesia doesn’t involve the practice of medicine. That cavalier attitude and total lack of understanding is what kills patients. I’ve seen it. Then again if that is the CRNAs argument for not requiring a physician to have ultimate responsibility of the patient in the OR, this turf battle will not end well for you guys.

Comment by Anesthesiologist — September 9, 2010 @ 11:19 am

It’s clearly a threatening topic for MDAs that the question of “equivalent care” has been breached, even if one commentator suggests the topic comes from a study that was “graduate work at best” and “funded by the AANA.” The fact is that the question of quality of care emerged from the history of anesthesiology since its inception. Nurses have been providing anesthesia as long as physicians, and in sheer numbers, I believe, provide more anesthetics in the United States. It may be that the best response from MDAs is silence, since we are not likely to defend our cause by creating enemies with a group of professionals who have as much, if not more, public trust that we ourselves enjoy. Furthermore, it seems clear to me, from simple observation, that there are CRNAs who are better anesthesia providers than some MDAs; likewise, there are MDAs who are better anesthesia providers than some CRNAs. We don’t need any study to verify this observation, but we may need to develop a tool that evaluates patient outcomes and costs relative to a given anesthesia provider, CRNA or MDA. And then, we’ll see who really provides both efficient and safe anesthesia care. We’ll only pay the providers who meet the standards of the evaluative tool. That time, which I welcome, is upon us. Personally, in our facility, where opt-out hasn’t been a factor, the “production problem” arises from the fact that MDAs are required to “observe four patients.” In reality, the CRNAs provide the bulk of the anesthesia care, while we evaluate patients, provide regional services, and help CRNAs and colleagues trouble-shoot problems as they arise in the O.R. I suspect that a CRNA could do this as easily, and in some cases, better than we do. Often, as you might imagine, this task load is impossible or very difficult for some MDAs to do well. Ultimately, the drive for production is the true enemy of patient safety. If patients knew how superficially some MDAs (or CRNAs) passed over their anesthetic plan, they’d certainly refuse to go under anesthesia from either a CRNA or an MDA. Essentially, the problem that is brought into view is the breach of public trust that has been manufactured by inflated healthcare costs. In other words, are MDAs really worth their cost? My answer: probably not, but then again the same could be said of many medical specialties. Again, with the caveat: it depends on the provider. Some are worth what they are compensated, while others are not. Ultimately, arguments aside, the modern success of MDAs and CRNAs alike resides with the advances in pharmacology and technology, and also because the utilitarian curve for human morbidity and mortality is tolerable to the public and to the profession. We need more sensitive measures than mortality. Perhaps too, is the likelihood that CRNA education is rigorous enough in most cases to meet the demands of the field. If CRNAs hadn’t been so educationally demanding of their ilk, they might not have been as successful as they are. One only needs to look at the Anesthesiology Assistant project to ascertain that there are very few AAs who are in the same ballpark as most CRNAs. While it shames me to say so, there are plenty of CRNAs who I work with that understand anesthesia and human pathophysiology as deeply, if not better, than many of my colleagues. Sadly, too, I suspect there many MDAs who can’t turn over cases like many of the CRNAs where I work. Perhaps this seemingly unique CRNA capacity is also a function of their education and professional formation, maybe one that needs to be addressed in MDA education.

Comment by Michael — September 9, 2010 @ 7:32 pm

In response to Michael 2?, (I write that because I am not sure if Michael 1 is intelligent enough to type 2 posts in one week, just read above and you’ll understand).

Just to let you know, this issue will never threaten me. I am a physician who trained at one of the most prestigious hospitals in the world. I am boarded in anesthesia and periop TEE. I have extra training in clinical ultrasound, peds, and medical technology. My present facility is a high acuity community hospital (900 beds, 1000+ hearts, premies, neuro, major vascular, 7000+ deliveries/year). No CRNA has a better understanding of human physiology than any of our MDAs (26 of us). I would let our CRNAs take care of my family, but not without a physician 2 steps away. It is unbelievable that I have to state this but, myself and my physician colleagues are better trained in the practice of medicine than any nurse with which I work. I am sorry you work with such a weak group; it is not the norm to reassure you.

The main issue is this. Does medical practice stop at the door to the preop, OR, and postop areas in this country (I say this country because most don’t let nurses do anesthesia, with which I disagree)? Is there some magical dust that takes away diagnosed and non-diagnosed disease in one of the most physiological intense periods in a patient’s life? If you are a supporter of the AANA, you would say yes. If you are rational, whether you are medically trained or not, you would say no. If disease is addressed in the perioperative setting, then physicans are needed.

I agree the ratio set by the government is based on…well not much. At my main hospital, 1 to 3 should be the max, as it cares for very sick patients. At our outpatient centers 1 to 6 or 8 would be more rational. A significant component of anesthesia care is nursing, and I will not argue that. But another component directly interfaces with medical care. Data from high volume practices will elucidate these issues.

But I will never let a nurse be in charge of the medical care of a patient where I work. I have emailed this Cromwell character (the author of this “junk science”) 5 times, without response. He is like some folklore figure that won’t communicate with the brain trust of anesthesia (the physicians). Every time his rubbish hits the paper, the ASA PAC grows faster and faster. It is now larger than the AMA’s. So be careful for which you ask. I love working with CRNAs, but if I have to support AA programs to keep physicans in the OR, I personally with contribute a large sum of money, as will tens of thousands of physicians trained in anesthesia.

And if Cromwell needs to use this flimsy science as a vehicle for the AANA, wait until he needs to compare AAs to CRNAs. He’ll be going to the septic tank for that “study.”

Comment by Anesthesiologist — September 9, 2010 @ 11:36 pm

Dear Anesthesiologist,
I’m not here to defend CRNAs. I’ve just noted the defensiveness that some MDAs have toward this issue. I’m not sure I understand the response. While you say you’re not threatened, you sound defensive in your response. Thus my further question is “Why?” It is yours and the tone of colleagues that I referred to when I said “threatened.” I suspect your confidence was earned by hours of hard labor and training, as it was by most of us. It is clear to me, however, that CRNAs have a strong history of their own that is marked by rigorous training and experience, albeit different than our own. In addition, nurses, in general, have always been the “whipping boys” of physicians and that has always bothered me. It bothers me because I have multiple family members who are advanced practice nurses who provide tremendous care to patients. I am careful to not diminish this quality by suggesting my own training is superior. I’ve come to accept that it is different, that it doesn’t necessarily produce a better end product for a given specialty of medical practice. I just have never been able to make the jump of saying, as you do, that “I would let our CRNAs take care of my family, but not without a physician 2 steps away.” It belies a sense of arrogance that doesn’t seem unqualifiably justified to me. Please don’t take offense. I can’t agree with your statement because I don’t feel it’s true. Conversely, I could say that “there are some CRNAs who I would let take care of my family (some I would not) and that there are some MDAs who I would let take care of my family (some I would not).” I’ll see if I can’t find more on Cromwell myself. I didn’t pursue this as you did, since it didn’t surprise me as much as it has seemed to surprise you.

Comment by Michael 2 — September 10, 2010 @ 7:12 pm

Michael 2,

No offense taken. I understand where you are coming from. I will talk to an SRNA all the way to the president of the AANA about this issue without hesitation and reservation. I was just talking to one of my favorite anesthetists last night at work about this issue. And imagine, we pretty much agree with one another. I really am not threatened by this issue (CRNAs won’t practice independently where I work, nor do they have interest in doing so). If you would be comfortable without a physician (MDA or surgeon) being in charge of your family member while in the OR (I’m not talking about the anesthesia, but the medical status of the patient), that is your choice and belief. Hell would freeze over for my son to go into a situation like that. I understand a small percentage of MDAs have taken advantage of the situation, but that is not the norm (at least where I have trained and work presently). When a CRNA needs me, I’m there FAST (like sprinting down the hall fast). I will do anything I can to make sure our anesthetists are comfortable (clinically, etc.) in their rooms, and are respected by all staff and surgeons in my OR. They indeed have the skills and training to demand such a situation.

Again the basic question is, should policy in this country have “doctors of nurse practice” have free reign to practice medicine and surgery. That is what is coming. Dr. Parker’s analogy with an orthopedic technician may sound impossible, but it may be coming (and I add general surgery, neurosurgery, cardiothoracic surgery technician). Just read the internet and look at nursing and physician assistant political updates. This is not just an anesthesia issue, it is across all components of medical care, and Obamacare is the perfect set up for nursing organizations to push their agenda. Cost cutting is THE goal. Maybe it’s because I’m crazy or I’m old school, but I think MDs/DOs should have the ultimate responsiblity. I’ve never seen a CRNA go out with a surgeon to talk to the family when there is a death or major complication. I’ve had that unpleasant experience several times. I am constantly put into situations where I drawn on my medical education and use my clinical decision making, to make the ultimate decision in the care of the patient. I think patients deserve that.

I don’t think CRNAs should be limited to practice in rural areas where physicians aren’t available or willing to take medical responsibility of the anesthetist. That deprives patients of needed operations. I don’t have a solution for that problem I must say, but I don’t think the answer is, lift the requirement that a physician has the ultimate responsiblity of the patient (which is essentially what the opt out is saying).

Thanks for you comments. When I talk to people about this issue they realize, we all are not that different in our goals and beliefs. Fortunately it is only the fringe groups in the ASA that believe MDAs are “better” than CRNAs, and that AANA members believe MDAs provide no additional benefit in the care of the surgical patient. We’ll all get along some time (because physicans aren’t going way, and nurses aren’t going way), but I must voice my opinion (verbally and through PAC funding), that physicians will continue to be the leaders of medical care.

Regards.

Comment by Anesthesiolosist — September 11, 2010 @ 9:34 am

In the end, the free market will settle this matter.

Comment by Free Market — September 12, 2010 @ 10:40 am

Agreed. I just wish the free market would settle lawyers versus paralegals and politicians versus their second/third in command. That would save some big money. Won’t happen through, the lawyers and politicians control the laws.

Comment by Anesthesiologist — September 12, 2010 @ 2:30 pm

As an independant rural anesthetist at a 25 bed hospital, I have no anesthesiologist present to supervise me. However, physicians still may guide my clincial practice.

My clinical decisions may be based upon practice advisories by the American Society of Anesthesiologists, the American Association of Nurse Anesthetists, the Anesthesia Patient Safety Foundation, or the American Society of Regional Anesthesia, or the American College of Cardiology. These practice advisories are multidisciplinary guidelines issued from research review that guide expert advise in both clinical and legal decisions regarding standards of care. I encourage our surgeons to practice from an evidence-based medicine standards in collaboration for decisions regarding patient care.

While my clinical practice does not require physician supervision, it is the knowledge base created by physician anesthesiologist that guides my clinical decisions. Respect for physician’s contribution to the specialty of anesthesiology is important to enhance patient care and safety and improve relationships with nurse anesthetists.

Comment by Carol Norred, CRNA PhD — September 13, 2010 @ 11:12 am

Carol,

Much appreciation to you for your comments, and I agree with your surgery recommendation. I am a very pro nurse anesthetist MDA. My main thing is, I just want siginificant and central physician involvement in the perioperative patient (and not necessarily supervising every case or in every area of the country– I know that is unrealistic). It is my perception (I may be incorrect) that a faction of the AANA feels physician involvement is unnecessary in the care of the perioperative patient.

In any case, I would want to practice in no other system than the anesthesia care team. That is the way the ICU works, and I believe that is the way the OR should work. I just hope we can come together to join forces (because let’s face it, whether one likes it or not, MDAs and CRNAs aren’t going anywhere, especially with surgical volume increasing nationally). Our enemy is the government, and they will impact our practice.

Comment by Anesthesiologist — September 13, 2010 @ 2:57 pm

The government is exactly why we now have practice advisories to guide clinicians and reimbursement from CMS; additionally, Joint Commission follows these policies for clinical practice and accreditation of hospitals. When healthcare is socialized, we–both physicians and nurse anesthetists will all be mandated by government policies that are researched-based recommendations formed by institutions of medicine and somewhat nursing, for instance HRSA is controlled by PhD RNs. Under socialized medicine, (God forbid) unfortunately there will be no more turf battles because we will all be making beans.

Comment by Carol Norred, CRNA PhD — September 13, 2010 @ 7:58 pm

Equivalent care indicates equivalent ability which indicates equivalent training, I challenge the CRNA’s here to take ABA exam…let’s see what you’re online nursing degree and BS ICU training and SRNA school gets u. Furthermore, I have spent 12 weeks on Anesthesia rotations and three different Level 1 Academic trauma centers one with an CRNA school. None of these places had any heart, head, transplant or complicated case with CRNA’s in the room. Whoever said CRNA’s handle such cases imo is lying. When patients start dying like they are in Iowa from the arrogant idiocy of CRNA’s this debate will be settled.

Comment by Medical Student — September 16, 2010 @ 12:18 am

I know a number of well-trained, excellent CRNA’s. As competent as they are however, nurses just do not have the same mentality with accepting 100% responsibility of the buck stopping here. They want the responsibility until they are in over their head or something goes wrong, then they are quick to say “I’m just a nurse, not a physician.” Their education and training is diferent. Their philosophy and approach to disease and pathology is different. For the time being, I am hoping that MD anesthesia participation remains the standard of care.

Comment by David, Surgeon — September 16, 2010 @ 2:11 pm

Medical Student,
I feel that I must disagree with you. “Equivalent care indicates equivalent ability which indicates equivalent training”. If this were true, all physicians would be of the same ability and skill. This is not reality. I am still a student registered nurse anesthetist, and while my educational background is certainly not medical school, I think that you would encounter quite a few physicians that find value in my “online nursing degree and BS ICU training”. “SRNA school” is by no means a cakewalk, at least not at my institution. The medical school here is exceptional as well. Comparing the two is not as simple as applying the argument that since A is not the same as B, A must be superior to B. I do respect the extended education in medicine that the physicians have, and do not believe that CRNAs are better physicians than anesthesiologists. That is not the argument. From my admittedly limited experience, and study of the research, I can say that there appears to be little or no difference in the safety of anesthesia administered by nurse anesthetists and physician anesthesiologists. You do your own argument no justice by attempting to trash the education of others. You are, after all, only a student yourself…

Comment by SRNA — September 18, 2010 @ 1:56 pm

As a CRNA who has practiced in small rural facilities for 36 years without an anesthesiologist,
medical direction or supervision, I can say this difference of opinion about CRNAs will never
end. I have heard surgeons say if a patient dies and a doctor is at the head of the table we
will consider it an “act of God”, but if a nurse is at the head of the table we will have to assume
the nurse did something to cause the death. As statistics indicate there is enough surgery
requiring anesthesia so that both our groups(CRNA& MDA)will be needed. If a surgeon will
not work with CRNAs so be it, someone else will.
Finally I think the biggest objection CRNAs have to anesthesiologists is the TEFRA requirements. To be followed around like a convicted felon whenever you approach a Patient
is not only annoying but humilating. On very very rare occasions I have worked in the ACT, and
I don’t think there are many physicians who could tolerate that kind of behavior. The ACT
practices I worked in I had to be escortedby the MDA into the OR for induction, then the
physician would tell me what medications to use, make frequent return visits to the OR to see
if the Patient was still alive, and finally not being allowed to wake the patient up till an MDA was available . I think CRNAs should be allowed to practice independently anywhere in this country. If we need help, we have the knowledge,education, and experience to ask for it.

Comment by Susan Kennedy CRNA — September 19, 2010 @ 11:52 am

I have worked in ACT, but 90% of my career has been in unsupervised/solo settings. I think MD anesthesiologists have made and will continue to make great contributions to the science and advancement of anesthesiology. I also think that the notion that “if you did not learn as I did, then you did not learn” is ridiculous. CRNAs, believe it or not, have the opportunity to learn the same science and read the same books. I have worked alongside many MDAs who had significantly more training/education in certain areas and significantly LESS training/education in others. Often, in some areas, my own training was more comprehensive than the MDA’s training. We all know (if we are being truthful) that in time our scientific knowledge base requires nurturing and continued education (we forget with age!). We also (should) know that the art of administering quality anesthesia to patients of all complexities is a talent that develops with time and practice. Anyone who claims 100% retention of their training and education are lying. So, if what we have learned cannot totally be quantified, and what we have retained cannot be totally quantified, then how are we to measure CRNA vs MDA? Reason would suggest studies of outcomes would be a good place to start.

Comment by Solo CRNA — September 20, 2010 @ 6:42 pm

The question is: are medical school required or should the future care givers just go to graduate school?

Comment by Eddie — September 21, 2010 @ 12:15 pm

Will the current class of residents and med students have a class action suit against the medical schools for misrepresentation and/or breach of contract? Should there be informed consent on the medical profession? Are the medical schools revealing the future to the earnest, idealistic applicants? Should they be required to disclose that 200 to 300K, plus 7-10 years of training will only lead to obsolesence?
I know of one physician who encourages all applicants and med students to switch and become a CRNA, 2-3 yrs post college and you are as good as the person who spent 3x as long.

Comment by Ignatz Osler — September 21, 2010 @ 10:13 pm

It is not just anesthesia folks. It is happening in other fields too.

There are newly flourishing fields where there are not many physicians willing, that’s filled with nurses, PAs and basic sc. PhDs. Thanks to Google et tu. Had once an interesting conversation trying to convince Pre-menstrual dysmorphic disorder theory with a nurse who was senior management and another time- that Pap stain is not cervix specific. There is mediocrity in them in the medical academia sense but there are smart ones who could have been fine physicians given their depth and adaptibility to re-learn.

The foreign MDs are some of the best with all their MD training, coming over to train again. While being dog in the manger with those foreign meds, the mediocrity is sitting with you MDs, as BSNs inside the fence. Go figure.

The only saving grace, would rather prefer the experienced and smart nurse to the rich cousin of mine who barely made it through high school and her dad sent her to the ‘medical school’ bought with lots of money. She is now a practising ‘surgeon’. (shudder)

My question is: why not give a disclaimer/waiver form before surgery to the patient: are you willing to go under knife if it is a nurse anesthetist. If he refuses, you have your answer- who do the patient trust.

And to nurses and non-MDs: if you want to get into the MD field, why not pay those hefty tuitions, take loans, MCATs and get into med school and join the MD ranks the right way? Wonder why us MDs are hostile to you guys!

Comment by Moi too syndrome — September 23, 2010 @ 12:39 am

I agree to both parties. We know challange is everywhere. Medical profession is very demanding and challening than any other profession. So every person who wish to be a good caregiver either MD or Nurses should start at the base point. I mean from junior school grade to the USMLE/Board certified exam. I will not blame MD or Nurses. Its all about effectiveness of the policy. In the long run replacement will not be effective and deliver a suboptimal result. High quality care depends on professionalism and knowledge. Dedication is very excellent part but could not replace knowledge and wisdom. Thanks

Comment by Open View — September 23, 2010 @ 2:47 am

Let’s face it, the whole crunch is about $$. Whether the provision and care is from a qualified CRNA or a qualified MDA, the bottom line is money. But, I can honestly say from visual experience, there are MDA’s, Surgeons, Physician’s, and CRNA’s that I would not allow to touch me or my family. In all these comments, there is not one suggestion about patient safety? It is reality that anyone can go for education and pay for the education, and practice for the money, but where does patient safety fall? The MDA’s continue to not allow regional anesthesia to be performed by a CRNA, and this is because it would take $$ out of their pockets. An epidural or spinal can be placed by any CRNA or MDA, yet the outcomes and success of placing one, can be from any person who has the skill and the feel for placing them. Being a patient care provider takes commitment to provide the safest and best medical intervention to any patient. CRNA education is rigorous and a provider that takes their educaiton seriously, is qualified in most all aspects. Yet if any patient care provider does not keep up with their education~it is lost. If a person does not continue learning and keep up with new technology and research, they should not be performing patient care. CRNA’s are perfectly capable of providing anesthesia without an MDA in most settings, and yes look at the background of nurses and nurse anesthesia providers. Our society is a rapid paced and growing technology based environment, and we need to roll with the times, not fight them. There is a place for MDA’s in large level 1 facilities or other urban hospitals. But, in the office-based setting or day surgery centers, is it really needed? Even in the large level 1 facility that I come from in Michigan, the MDA comes out of their sleep room when there is a problem or a code. Otherwise, they may be placing an epidural in L&D or sleeping. But when it comes to providing a team approach for patient safety, the work is left up to the CRNA. What is the MDA getting paid for? And how much is he/she getting paid? These are the issues that continue to increase medical costs and cause such financial burdens in the medical arena. Physicians offices also-they send 3 minutes with the patient and get paid what? We need to think about patient safety and keep in mind that extra costs is what has gotten our new Obama laws in the first place. What is the safest for the patient? Is a fee for MDA really necessary? In what setting are you practicing in? And, is the team approach for the patients best interest? Or is it financial? MDA’s make the final decisions about what anesthetic sequence is to be used on a particular patient and they carry the malpractice liability insurance. We need to decide what is the best for cost containment and patient safety as a team approach.

Comment by rg-SRNA — September 30, 2010 @ 5:22 pm

You dear sir need to wake up and smell the coffee. Do you know who is taking care of Americans in the rural areas where the MDs do not wish to reside? I work with an MD who is less competent than an SRNA. He sits in his office and plays videos on the computer while we are in the OR taking care of the patients. You need to research your topic before you write about it.

Comment by NazNIN LALANI — October 1, 2010 @ 7:14 pm

“Anesthesiologist” — for someone so busy, you have a lot of time to read and write comments. Perhaps because CRNAs are doing all of your work?

Comment by Brian — October 4, 2010 @ 10:58 am

“Moi Too” — The general public may surprise you. I think your assumption is banking on the notion that the opinion towards physicians has not been tainted over the years. Hmmm. My patients have great confidence when I can assure them that I will personally see to their well-being while under the knife. The patients are not stupid, they know that we all have to pass exams and get licensed to provide anesthesia. From a patient perspective, what matters is what are YOU going to do to ensure MY safety. I doubt they care if you had an extra 3 years “in training.” If you are still speaking of your training, while in private practice, who are you trying to impress?

Comment by Solo CRNA — October 13, 2010 @ 10:10 am

Good points by all……..except the medical student. He/she sounds really immature and I’m thinking should find another profession as I hear not a shred of intelligence in that post. Very ignorant person. CRNAs and MDAs all have a role to fill ……….I am a CRNA who has worked alongside both…..there are good and bad in both professions.

Comment by Dan — December 4, 2010 @ 7:35 pm

I am a CRNA and have been practicing solo for over 14 years in a wide variety of settings. I detect a sense of desperation in the postings of my MDA colleagues. I don’t blame them. I would feel the same way placed in their present situation. The opt-out provision of Medicare has provided a body of data regarding anesthetic outcomes that any researcher would envy. The incontrovertible conclusion is that given similar patient loads, outcomes are basically the same regardless of whether the anesthesia provider is a CRNA, MDA or both working together. I suppose its hard to swallow, but there seems to be a level of education in anesthesia past which no further benefit is observed. Would physicians completing a 4 year anesthesia residency be only half as competent as one training in a hypothetical 8 year residency? Probably not. Furthermore, patients RARELY care if their anesthetist is a CRNA or physician. One patient in the last 14 years voiced concern. This patient happened to be acquainted with a cardiothoracic surgeon with whom I worked. He assured her of his confidence in my skills, and we proceeded without incident. In the preface of Dr Adrianni”s classic text, he states that CRNAs can, through diligent training and career-long reading and research easily bridge the “gap” in education between physicians and themselves. Another item that bears mentioning regarding some of the advanced skills listed by the anesthesiologist above are a result of biased opportunities in many institutions. Does he really believe that a CRNA couldn’t, given the same trainig learn to be equally as competent in the use of TEE and ultrasound techniques? For example, I performed only a handful of central lines as a SRNA. But while doing cardiac anesthesia daily for 5 years and placing central lines/Swans daily, became very proficient and was occasionally called on by the surgeon to place them after an anesthesiologist with less experience ran into difficulty. If MDAs are really interested in safe patient care, perhaps they could remove these training barriers so everyone’s competency is enhanced. I could go on, but the turf warfare is transparently dollar-driven. In these recession-riven times, not a very sympathetic position.

Comment by GeorgiaCRNA — December 5, 2010 @ 10:40 am

Michael’s comment of Sept. 9, 2010 was dead on. As a CRNA who has practiced for over 15 years, I have worked with both MDA and CRNA practitioners who I would allow to care for my family members without reservation. Likewise, there are MDAs and CRNA that I would not let put my dog to sleep.

“Anesthesiologist” is clearly threatened, despite his claims to the contrary.

Michael is correct that many CRNA’s knowledge of anatomy and physiology is superb. (And some – not so much.) We study from the same textbooks as our MDA colleagues, train in the same ORs, and often have the same attending physicians or CRNAs during our training periods.

I would like to ask “Anesthesiologist” how long a CRNA has to practice in a high acuity, tertiary care setting, giving anesthesia daily with minimal to no supervision (as I did for 5 years) before he or she is as competent as a newly graduated resident.

Comment by David — May 25, 2011 @ 10:17 pm

Do ypu think that anesthesia is the practice of medicine or nursing? If nursing, allow a nurse (CRNA) ; if medicine demand a physician (anesthesiologist)..anyone who compares the two is sadly lacking inn a number of areas……cheers

Comment by gareth — October 23, 2011 @ 11:04 pm

I recently needed surgery: I’m a 57 year old bloke who graduated from med school long age….my job is research, my wife is an advance practice NP….I certianly don’t want to offent CRNA BUTlimey, they are highly-trained nurses not physicians..and nobody in the know wants an unsupervised crna doing their anesthesia….

Comment by micky — December 26, 2011 @ 10:31 pm