Nov
27

Is the Pain Worth it?

By

Its always nice to hear from former classmates and today was no exception.  Mel moved with her husband out to Florida after graduation and is now working and living it up in the Sun State with her husband.  While going through the “educational process” of becoming a CRNA here at the University of Southern California, all of the difficulties and seemingly unending struggles both in the classroom and in clinical rotations tend to dull the enthusiasm a bit.

Mel never lost here enthusiasm through loss of sleep and all the struggles SRNA’s go through.

Here is her letter to Dr. Michele Gold the program director at USC that puts it all in perspective:

Hi Dr Gold,

I just needed to drop you a quick line to Thank You and all of my preceptors and teachers at USC. As you know, I am out here in Florida, and it has been a real eye-opener as to the superior education and training that I have received at USC compared to (unfortunately) a lot of new graduates and students that I have come in contact with.  It has made me appreciate my “painful” two years even more….and I never thought Id say that Hope all is well with you and the program, we are loving our new life in Florida.

Sincerely,
Mel

Its a good thing for current students and candidates to any nurse anesthesia program to hear the stories of others however brief.  During our time in “The Program” at USC Mel and I did struggle more than a few times with what seemed at the time to be unreasonable expectations.  To say that its tough to become a CRNA is a true statement.  Think about it.  Would you want some lazy inattentive provider giving anesthesia to your grandmother?  Wouldn’t you want the brightest most vigilant anesthetist with the experience to handle any difficulty during the anesthetic to be at the head of the bed.  That’s what all anesthesia providers strive for whether physician or nurse anesthetist.

A case in point.  Yesterday afternoon a gun shot wound victim was “RB’d” to the OR.  Three CRNA’s and a first year resident were on hand to start the case that very quickly required all the standard lines, arterial central and multiple large peripheral IV’s.  We began the case immediately when the guy arrived with a Level One rapid infuser in the room.  We ended the case the two Level One’s going for volume resuscitation, I was giving a lot of blood products.  After an hour and a half the surgeons were mopping up and the attending anesthesiologist walked back in the room and smiled saying what a great job we all had done. Thankfully these kind of cases are not common out in the community.  But here at the largest level one trauma center in Los Angele’s we see a variety of crazy things from massive trauma from train wrecks, car crashes and of course the “knife and gun” club action.

I am glad that the training we received has prepared us to handle these as well as the routine.

Categories : Student Life

Comments

  1. Sue says:

    I love the comment above: Wouldn’t you want the brightest most vigilant anesthetist ? No, I want an anesthesiologist (MD). not a nurse (CRNA). I just had anesthesia from an all MD practice and none of them would consent to CRNA-provided anesthesia despite all of the cheerleading. When BC/BS told me that a CRNA would cost the same as an anesthesiologist, my choice was simple. My surgeon agreed: get an anesthesiologist; that’s who the CRNA’s call if anything goes wrong..

  2. David says:

    Sue,

    I believe you are totally wrong about your feelings. The “Brightest and most vigilant” anesthesia provider is not necessarily an MD nor is it necessarily a nurse anesthetist. It just depends on the provider.

    Statistics show that there is NO difference between the two groups as a whole as far as safety outcome criteria is concerned. All I know is that NO one is more vigilant or “brighter” than me! Maybe I am a little prejudiced but no one can give a better anesthetic for any procedure than a nurse anesthetist. I stand by that statement. (Tongue in Cheek OK)

    I have total respect for my anesthesia MD friends that I work with, I have bailed them out countless times. To be honest, we have bailed each other out many times for which I am grateful.

    Sue, you sound sincere if misguided. Your comment sounds to me to be politically motivated and not at all about a reflection on the original topic of the post but I allowed the comment anyway. It will show the desperation of some groups and their paranoia. Nurse anesthetists are used to this.

    It is with great pleasure that I work in a team environment with MD’s but I do not in any respect think that they are more than half of the equation.

    DG

  3. Kendra R says:

    Sue
    I speak from a bit of an outsider’s prospective. I am hoping to get into CRNA school, but I work with a plastic surgeon and we do surgeries with many anesthesiologists from a specific practice. Every one of them that I have spoken to have very clearly stated that they would have no problem working with CRNA’s. They seem to believe the skill level is very much the same and would feel VERY comfortable with placing the care of their patients in the hands of a well trained CRNA. The only issue is politics.

    Sue, do you understand why an MD would be against an RN doing something that they do just as well as they do it? Perhaps the fact that a CRNA is paid less but does the same thing brings up concerns for the stability of their jobs. I’m sure you would do everything you could to keep from loosing work.

    The botom line is this. Political opinions do not have anything to do with skill level. Please remember that.

  4. Gary says:

    I totally agree with Sue’s original comments. I have nothing against CRNA’s, if a patient wants to receive anesthesia from a nurse (CRNA) that’s fine with me. I do not and don’t believe that a CRNA will ever equal an anesthesiologist, but I believe that they have a role (closely supervised). I was attended to by a capable CRNA at a hospital while serving in the military; I was severely burned while my aircraft was being refuled and I was glad to have the CRNA while I underwent lengthly debridements and skin grafts. CRNA’s were all the military had, but I have to say that my CRNA did a great job. She kept my screaming to a minimum, so I’m grateful. But back in civilian life, I’ll choose an anesthesiologist. My wife is a physician and agrees that CRNA’s are useful when supervised. I can’t see where a CRNA’s salary is relevant to this discussion; for me it’s all about patient safety. My salary is in excess of most physicians and (thankfully) I can see any practitioner that I want to see. My choice is an anesthesiologist not a CRNA, but that doesn’t mean that I think that nurses are unqualified for advanced roles. My PCP (I guess PCNP) is a nurse practitioner and she’s as sharp a any doctor…..I just don’t think that anesthesia is a safe arena for CRNA’s to practice without supervision.

  5. David says:

    There is NO EVIDENCE that an MD anesthesia provider is safer than a Nurse anesthetist. Don’t go around spouting nonsense. If you feel more comfortable with an anesthesiologist that is fine but do not tell me or any others that nurse anesthetists are not safe. You are totally wrong and the courts have supported the evidence. If you want to see real evidence that CRNA’s results are as good as any provider check this study.

  6. I being an Anesthesiologist myself, agree that there is no difference as such with regards to safety between an CRNA and a n anesthetist. We all need to understand that both play an important role in providing better and safe health care. If there would have been any issues with safety, then which surgeon would choose a CRNA. The reason why CRNA’s are called is that they are equivalent in providing safe anesthesia and emergency services.

  7. gary hater says:

    There are just some people who are so uneducated that they think certain titles, i.e. NURSE anesthetist, are important. By the way Gary, your wife is a physician, but IS SHE AN ANESTHESIOLOGIST? No? Well, then she probably wouldn’t know much about being an anesthesiologist OR a CRNA. Some people are just ignorant (edit). Oh and by the way, you probably think that if something costs more than it must be better. Ignorant (expletive edit).

  8. David says:

    Thank you sir for being a voice of reason is a sea of confusion. There is NO difference with regards to safety between a CRNA and an anesthesiologist. I totally agree. Now is there a difference between an anesthesiologist and a nurse anesthetist, yes. Discovering the differences and putting them to the best use for the patient is what is most important.

    I did an AAA today and consulted with an anesthesiologist that does lots of these cases. This was very useful to me and to the surgical outcome for the patient. The bottom line in my opinion is, there is room for all of us. We just have to find our place. And that is what all the commotion is about. What is the roll that we are to play.

  9. anesthesia common sense says:

    CRNA’s have a role, as nurses who should be supervised. Nothing more, nothing less. Nobody who is being honest with themselves would equate nursing school (crna) with med school. Dave, you are entitled to your opinion but it makes no sense. I’m glad that my hospital will never allow “solo” crna practice. “anesthesia general” is obviously a nurse. sorry, my opinion of crna just dropped a huge notch; and in my hospital, that means something to a lot of people.

  10. David says:

    Anes@yahoo.com,

    Thank you for your comment at nurseanesthetist.org. I think you may have mistaken me for someone else. I have never advocated for “solo” practice. In fact I work in a team anesthesia group and find it very rewarding. Perhaps you have mistaken my passion and advocacy when someone says that nurse anesthetists are not “safe”. To that comment I will fight to the last drop. If you say that we can work together and take care of patients I will support you. If you say that I am not safe to practice anesthesia I will object vehemently. I really am a nice person you know.

    By the way, Your email is FAKE. So what does that say about you?

    David Godden

  11. Julie says:

    I do not care if it would be a CRNA or an MD anesthesiologist as long as they care about my life. I honestly did not know until I had teeth extracted there was a CRNA. However, when I ask her personally about being safer with an actual anesthesiologist she told me this “I have children at home, and so do you. I could not imagine going home to my children knowing I caused someones children to lose their mother today, therefore I could not do what I do if I was not confident with knowing you would wake up and go on with your life after I did my job”. That meant a lot to me and I trusted her because of that. I’m sure they could make a mistake but couldn’t an anesthesiologist make one as well?

  12. nancy says:

    if a nurse wants to do a physician’s job, she/he should go to med school, not “cut short” doing a 3-5 year course. Nurses should do what they are supposed to to, the same for MDs.
    What’s next? nurses should be called doctors and write MD. before their names?

  13. David says:

    Hmmm, I could write a whole post just on this one comment. Nancy, I refer you to this article which could partially answer your question if you are interested in one.

    “The Future of Nursing: Leading Change and Advancing Health” a report by the IOC (Institute of Medicine) found here:

    http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12956

  14. Lil says:

    Quick situation in the OR. The patient was coding and we needed fast intubation. The anesthesiologist freaked out really bad and started to yell,” call a doctor!” A CRNA came in and intubated the patient in a matter of seconds. This was too funny! It’s not the intials you get after your name, it’s the experience you have and what you can do in a crisis situation. Nothing bad against the MDs, I’m sure they have their share of jokes about CRNAs as well.

  15. Zack says:

    To Nancy, Gary and Sue, I have to say the attempt you’ve made to discredit CRNAs was definitely in vain. If you’ve ever received anesthesia whether it was in an OR at the best hospital in the country, or even at the orthodontists office, there is a pretty high chance that a CRNA put you under. In fact you can go to the biggest and best hospital in the United States and you will find anesthesia care teams that consist of CRNAS, AAs, and at most 4 anesthesiologists, and that is the biggest hospital in the United States.
    Also there are state laws that allow CRNAs to perform without the supervision of an anesthesiologist. I myself am CRNA and before I even start to try to sway anyones opinion on this matter. It would only be sensible to inform them of the history of anesthesia in the US. More than a generation and a half ago nurses were the only medical professionals that were competent in anesthesia. As of now more than half of the anesthetics in the US are administered by Nurse anesthetists. And funny thing is right here Nancy Gary and Sue CRNAs have been given the right by mandated laws to practice with autonomy no matter the setting, OR, ICU, ER. Looking at this from an International perspective the laws that govern CRNAs the US are by far the strictest. The only state that mandates an MD be present during CRNA performing anesthesia is Georgia, and the MD doesn’t even have to be an anesthesiologist. You three buffoons need to understand that CRNAs deal with very complicated life or death situations that you should appreciate much less try and discredit. For Nancy Gary and Sue, it is obvious none of you know what your talking about, so please do everyone a huge favor and keep your hilarious opinions to yourselves.

  16. Az says:

    There are good nurses and bad nurses as well as good and bad doctors. Just pray that you end up in the hands of the good ones and not the bad ones. Good nurses are better than bad doctors.

  17. Tamra Kelly says:

    Interesting blogging here. I just had to comment. First of all, Who gave Michael Jackson Propofol?? An M.D. thats who. Propofol, a drug that should only be given in hospital type environment, where the patients vital signs are continuously monitored, where there is a CRASH CART, and INTUBATION TRAY, and AMBU BAG MASK AND SUCTION!! Not in the HOME! Ok heres my background. . . 7.5yr RN in PEDIATRIC ICU. Ive given lots of different sedatives, including propofol. Ive managed drips. Ive managed post open heart surguries on tiny babys, severe head trauma from car accidents, weird airways and congenital abnormalities. I can tell you many times when I was the one giving orders to the M.D.s, I think we should give the patient more sedation, more volume, intubate. Ive helped code patients, while barking out what drugs to draw up and what doses and how many ML to draw up, right on the top of my head. Because I am experienced and I know! So, here I am applying to CRNA school, so I can still perform handson skills on patients, except with school, I will not only know the dosages, but the chemical properties of these drugs, and the properties of anesthetic gas and how to give it safely. Why would I waste all my hard work and dedication. . . The purpose of advancing my degree is to be “specialized”. You be the judge, I think I have plenty of experience working under “MD” as I actually give these drugs, monitor the patients, and think critically already. And its not about just doing what the MD tells you to do, its also thinking about is this right for the patients safety, the right drug, the right route, the right patient, right dose, right vital signs and situation. I would be stopped short of my career if I dont advance now. Im ready to become a CRNA!!! Because I know I can be vigilant. . . trusted. . .. dedicated to patient safety! I already practice this as an RN

  18. phishman says:

    @Dave:
    Is there a difference between CRNA and an anesthesiologist for simple cases? Nope. Is there a difference for an ASA 4-5 case- you bet! The training a CRNA receives IS NOT THE SAME as that a physician receives and to convince one otherwise would be moronic. CRNAs are a great asset to an anesthesiology team but please stop citing your BS “research” about equality of MD VS CRNA published by your own lobbying group AASA- seriously what a joke! How can you even claim you are a creditable resource with this crap. Also I want to clarify for anyone reading this board- the training a CRNA receives does not equal that of a physician- Anesthesiologists receive training in other aspects of medicine including ICU care, pain management, sleep medicine, cardiac medicine etc. While you may not want to admit it, CRNA does not = anesthesiologist; ICU experience does not = anesthesiology residency trained heavy in ICU management; participating in a TEE does not = anesthesiology cardiac fellowship. I am not an anesthesiologist or a physician but some of the things implied from posts here are scary.

  19. David says:

    Phishman,
    Thank you for your comments. Of course there is a difference between nurse anesthesia providers and physician anesthesia providers. The MD’s have a very large scope of practice in peri-operative medicine which the nurse anesthetists do not have. Totally agreed.
    All I have been defending here is the idea that nurse anesthetists are safe, period. No mention of solo practice, OK.

    I am closing this crazy commenting on this issue. It has nothing to do with the purpose of this web site. The intent here is to encourage nurses to pursue anesthesia education and show them the way. Conflicts with our physician friends have no part of that.

  20. Josh says:

    David,
    Thank you so much for your intelligent and insightful responses. Its nurses such as yourself that make me proud to wear the RN title on my chest.
    With that being said, I think the bigger picture is being missed here. Healthcare will not discriminate between MD or RN when it comes to administration of anesthesia; an organization will look at safety and costs to determine who performs this role. As David has already pointed out through use of a respected study, the safety of anesthesia administration is the same whether through an MD or CRNA (as an earlier post argues, this study was not performed by the CRNA governing body AANA, only used to an article that sheds light on its findings, like countless others before it. Likewise, if the study had proven that CRNAs did in fact have lower safety outcomes, it would have been printed in a MEDICAL journal no doubt, but I digress).
    The other very important issue is cost, and lets be honest, CRNAs are cheaper. According to salary.com, CRNAs on average make almost 150,000 less per year than anesthesiologists.
    Paying 150,000 less a year PER anesthesia role with the same outcomes? You’re going to be hard pressed to find any institution not willing to make that deal.

  21. Chris S. says:

    Cardiac Surgeon here, here’s my two cents:

    First off, I work with CRNA, I enjoy working with CRNAs, and have nothing against them. I would just like to comment on these “studies” of safety that people keep quoting.

    The studies that quote “no difference” between outcomes between anesthesiologist and CRNA makes no sense to me. The quality of cases are very different between these two groups. For instance, yes there are CRNAs and MDs doing cardiac surgery cases that can be compared, however, there is probably no comparison between a CRNA and MD in a cardiac case with severe mitral valve regurgitation complicated by endocarditis requiring TEE. Simply because no group in their right mind or surgeon would have a CRNA manage that case without extremely close supervision by a MD.

    If I did a study between a PA vs. a 4th year surgical resident assisting a lap cholecystectomy and found that the surgical outcomes are the same, I would not generalize it as “its just as safe, so why hire a surgeon when you can have a PA for cheaper” If for some reason a vital structure is hit during this procedure, the 4th year surgical resident would have a far better understanding of what to do to keep the patient alive. And this is the main difference. It’s important to have the extra training when things go wrong. This is what makes it “safer” to have someone better trained.

    Similar to Anesthesia, when things go wrong, the CRNA calls for the Anesthesiologist.

    Again, my goal here is to not “put down” any one field. I just want to clarify how wrong a lot of people interpret various studies and make presumptions from them.

  22. David says:

    Chris,

    Thank you for your comments. I agree with everything you say pretty much. No arguments from me. Excluding the cardiac room I will say that I would put a seasoned CRNA in any room and have no problem trusting they would do a good and safe job.

    Advanced training is really important and I think that the physicians that do fellowships are especially qualified in their fields. I look to these for advice all the time and backup when needed.

    Again, thank you for taking the time to comment. The polictics of health care is really getting under peoples hide. Me, I just want to take care of patients and be a “Team” memeber.

    David Godden

  23. sandman says:

    David, I detect some misgivings on your part when it comes to solo CRNA Providers. Be careful friend, I and many others have been working solo for years. For the last 12 years I have been the sole provider in our rural facility. I have no problem doing so, and the literature supports the safe care we give everyday. Not just ACT settings, but ALL settings.

  24. I have been a CRNA for about two years, i live in a small area and we only have 2 CRNA’s and no anesthesiologist, and our patients seem to make it just fine!! 🙂

  25. Annette Shannon Smith, CRNA says:

    Yes, the pain is worth it! My training seemed like boot camp, but it just made me that much better of a CRNA, thank you to all my preceptors!

  26. Heather Raney says:

    It’s really unfortunate to see how misinformed people are about this topic. People say that 5 years of schooling to become a CRNA is no big deal. It isn’t easy. They are very qualified individuals. I would know, I’m in school for it. (: I appreciate the information and the article David. It makes me more motivated to reach my goal!

    -Heather Raney

  27. Robert Rothwell says:

    Hi David. First of all, is this DG that worked at UCLA on 4EICU? Anyway, I am trying to find out which CRNA schools are providing the most challenging cases. I don’t care about US news report lists etc. So,which schools have the most ‘street credit?’

    Thanks,

    Robert

  28. David says:

    Hi Roert,
    Yes this is DG the original. There are many schools that would provide you with challenging cases. Try going to the AANA web site and look at the programs in the States you are willing to travel to. Here is a link to get you started on your search.

    Become a CRNA: http://www.aana.com/ceandeducation/becomeacrna/Pages/default.aspx
    Council on Accreditation list by state of schools: http://home.coa.us.com/accredited-programs/Pages/default.aspx

    After you have wadded through the web sites of the potential schools you are will to apply to, here is a tip. First, be willing to travel. Some of the best schools may not be in the area that you are living in now. Second, just my bias but I love the program at Pit. They have one of the best simulation centers in the country. Here at USC, we have developed a Simulation program over the past several years that is starting to really shine. Pit’s simulation program however is fabulous as is the rest of their educational process in their SRNA program. Tip number three, see your future – be your future. Make up your mind and everything will fall into place.

    There is an old saying, “When the student is ready, the Teacher appears.” How true in so many areas. Once you are ready, by this I mean, have determined that you will be a CRNA and work for it every day, all the doors will open and the future you have envisioned will become a reality. Good luck Robert and I hope to see you here at USC.

    DG

  29. Logan Turner says:

    Hi David,

    Thanks for the great info on your site. I am very interested in your opinion on which schools produce highly trained fully competent (in all aspects of anesthesia) providers. I was accepted into school at KPSA and an alternate at VCU last year but was unable to attend due to extenuating circumstances. I am beginning the application process again and would love to attend one of the best programs out there.

    My short list is: USC, OHSU (oregon), Sammuel Merrit and now due to your bias/opinion, Pit.

    I understand that no one has knowledge of all 112 programs out there, but is there a general consensus in the anesthesia community of which programs provide top providers? (besides their own obviously…lol)

    p.s. hope to be doing a shadow or two @ USC within the next couple of months. Hope to see you there!

    Sincerely,

    Logan

  30. Ronald J. says:

    Hi David,

    What a great discussion here. This topic really sheds light on the issue of safety in anesthesia practice. This debate will continue to rumble through the ages. Who will deliver the best care? a CRNA or md? There will always be controversy in that respect. What the public must understand here is that it takes a TEAM to provide safe care (ie surgeon, first assist nurse, crna, anesthesiologist, circulating nurse, resident, etc) whether it’s a difficult case or not. Point is, CRNA’s currently deliver most anethesia care in the US, supervised or not, and will continue to deliver safe care for years to come. If it is an issue of research and its validity, then yes we must continue to conduct more extensive research in patient outcomes under the care of CRNA’s, including those “difficult ones”. It will not make a difference, we are safe. I am an ER nurse at a level one trauma hospital and will be applying to a CRNA program soon. Hopefully, i’ll be adding to this “controversy” through my practice, research and lobbying one day. I have to say, the future does look bright for CRNA’s.

    BTW, thanks David for the shadow!

    Ronald J, RN

  31. Linda C. says:

    To all that took the time to comment:

    I work in an open heart/CCU setting. I have contemplated for nine years to apply for CRNA school, but now it seems like the NP education is for me. The politics! Doesn’t anyone get exhausted by all of this? I had three children and all epidurals were given by CRNAs. They were competent and respected. However, to change careers to just have to prove my worthiness all over again is daunting. Keep up the great work. Not for me, but I now know why. Take care.

    Linda, PROUD RN BUT NOT CRNA MATERIAL

  32. David says:

    Linda,

    Yes you are right, not all can become nurse anesthetists. Its a very tough road.
    The Nurse Practitioner route is more accessible and easier. Ask me – I know – I am both.
    We need more good health care practitioners to take care of our growing population and Nurse Practitioners fill a vital role now and even more so in the future. Good luck.
    DG

  33. TK says:

    Im a Anesthesiologist with fellowship training in regional and trauma anesthesia. I went to four years of undergrad, four years of med school and completed 6 years of post medical school training. I took call every 4-6 days, responded to traumas/codes, published 6 papers and one book chapter, took more tests than i can remember and did thousands of cases mostly ASA III and IV. I have done heart, lung, liver, kidney, pancreatic and small bowel transplants. And throughout all of this I worked with CRNAs, NPs, and Physicians. Many were good, many were horrible. Like some have said I believe CRNAs are vital to the practice of anesthesia. Simply put, their is not enough money or physicians to provide for all anesthetics. At the same time, their are some glaring differences. Nurses have never advanced the modern field of anesthesiology. It is an expected part of any residency and academic employment to conduct research and advance the field. In my experience, nurses learn one routine and thats it. Just the other day a “Senior Nurse Anesthetist” argued with a resident about how “dumb it is to continue chest compressions while intubating”. That flies against huge critical care literature that now says keep doing compressions. But when you are not educated in a culture of life long learning, which physicians for the most part are, then this is what happens. Is this to say CRNAs are not smart, capable or worthy of providing anesthesia. I would say no. They are a vital part of the care team model. And I enjoy working with them every day. Most are hard working, kind and respectful. So I guess what I am trying to say is, CRNAs need to stop lying to themselves and trying to fool the public by saying MD Anesthesiologists are not more educated in the profession. The fact of the matter is I am living proof that we are. And I am just an average anesthesiologist. At the same time, to say that CRNAs are useless, dumb, etc is disrespectful, unkind and untrue. Everyone needs to calm down, think about the patients we treat and check our egos at the door.

  34. David says:

    I just sent an email to thank TK for his comments. The rule here is no correct email address no posting of comments. This is my house and the Free Speech rule does not apply.

    My house my rules and in the end I have sole responsibility for what is posted here.

    TK’s comments are really right on. To quote, “throughout all of this I worked with CRNAs, NPs, and Physicians. Many were good, many were horrible.” In my experience I find this to be true for all of the different groups including Physicians. So in the end, in my view, it is not the one with the most education that is the best provider but the person with judgement, skill and wisdom. I have seen of the groups mentioned fabulous anesthesia providers and some I would not want to anesthetize my dog. So, I do not think it is a question of education that any of us are arguing but of competency.

    Finally, I do thank you TK for your patient focus and the idea that there is great good in each of the anesthesia groups. For myself, I really enjoy the relationships I have with the Anesthesiologists I work with. It is a mutually beneficial relationship.

    This web site that I created was intended to be for the Nurse Anesthetist Student and those wanting to pursue the profession. Unfortunately, dealing with the political landscape is part of that path.

  35. G Hoke says:

    CRNAs perform a needed function. But there is a difference in the knowledge base and training. The studies funded by the AANA did not show a difference in outcomes, and I would say the difference is likely small (most of our CRNAs are very clinically competent), but I would wager there probably is a difference. I would say the biggest problem with identifying a difference in outcome originally is the fact that most CRNAs are protected from bad outcomes by having support from physicians (and not just anesthesiologists). And both bad anesthesiologists and bad CRNAs are protected by having physicians (sometimes critically care trained anesthesiologists, but never CRNAs) who salvage bad outcomes in the ICU.

    Two examples from the past week: A CRNA gave me a break. I specifically told them my patient had ARDS, and not to change my vent setting. I come back and find that the CRNA has switched my vent to pressure support mode and tidal volumes are now >6ml/kg. Will I be able to show a difference in how the patient does? No. Is the literature clear that the decision made to change modes results in mortality differences? Explicit. In another case this week, during a crani, the CRNA breaking me decided to tell the surgeon that the patient was experiencing high urine output and so likely had SIADH. I came back to the room to find her looking up dosing for administration of DDAVP (which she had just looked up as the treatment for SIADH). I had to politely tell the surgeon to forget about what she said, and that her medical knowledge was incorrect. These examples are common, and make me wonder if their is more of a Dunning–Kruger effect then they realize.

    In parting. There are some great CRNAs, and some dumb anesthesiologists, and I’d be more than happy to let most CRNAs provide my anesthetic. However, if I was unhealthy and had multiple comorbidities and was undergoing a high risk surgery, I’d handpick an anesthesiologist instead. There is a difference between providing an anesthetic and practicing medicine, and an anesthesiologist is the only one who can do both.

  36. David says:

    Sir,
    Thank you for your post and response to my email. I really appreciate it when someone is reasonable and will give their real email address so that I can contact them directly and discuss their viewpoint directly.

    I don’t know of any that would contest that physicians with 4 or more years of college and then 4 years of medical school not to mention residency has more “education” than the average CRNA with 4 years of college and several years of ICU training to get them in the door to a Masters program in Nurse Anesthesia.

    The only point I would question in your statement is the objection to the AANA sponsored study comparing CRNA practice to physician practice. You say, “I would say the biggest problem with identifying a difference in outcome originally is the fact that most CRNAs are protected from bad outcomes by having support from physicians”. Just to clarify, the study you mention has three arms; 1) CRNA solo practice; 2) physician solo practice and finally; 3) the anesthesia care team (ACT). In my reading of the reports the outcomes in the two solo practice arms of the very large study showed NO difference in mortality and morbidity. The interesting point I find funny is that in the ACT arm the evidence reported a slight decrease in morbidity. Now, I know that some one out there will jump up and say, “See, if an anesthesiologist is in the room there is a better outcome than in solo CRNA practice.” Hmmmmmm, I would say that you had better have a CRNA in the room because the solo physician practice has worse outcomes. So you must see the humor in this. Besides, the numbers indicating any difference are small.

    On a final note and I know you are taking notes, what physician group actually sits at the bedside paying attention to patients; gives medications; starts IV’s and routinely measures urine output; records vital signs in the medical record and does other numerous nursing functions? Anesthesiologists thats who. So my question is. If you want to do anesthesia why don’t you go to nursing school! That is in response to all of the unreasonable hardheaded physicians who ask CRNA’s, “If you want to practice medicine, why don’t you go to medical school”.

    So you have to see that there is some humor in all of this nonsensical debate and that in the end we are a blended group of physicians and nurses who end up doing pretty much the same thing. Don’t get all excited now, I am not saying we are all equal. CRNA’s are definitely different.

    This morning, my wife had ESS surgery at a large teaching institution. The attending surgeon never showed up to say hello prior to the surgery but his chief resident did. The anesthesiologist, my friend and his CRNA partner also my friend both did an in-depth interview of my wife prior to taking her back for surgery. Am I happy with the anesthesia care she got. You bet I am. Am I happy that the surgeon I requested to do the surgery was late, absolutely not. I know the surgery went well but there is a difference in providers and it does not come down to education.

  37. lisa says:

    You are right no one wants a substandard CRNA giving anesthesia to their grandmother. I really enjoy your writing. I am going to mention your blog on my nurse anesthetist blog

  38. JIM says:

    I am a CRNA… I have been working independently now for 8 years in a 135 bed hospital. We (4 CRNAs) have been doing so every since our surgeons removed the two (supervising MDAs) from the hospital. Or should I say the computers they played on and managed their investments from while we (CRNAs) ran the cases… our surgeons are very pleased with our (CRNAs) work and tell us so daily. I have even took care of three of their wives and two of them personally. And most recently placed a spinal in one of the surgeons daughters for a knee repair. Its only political…

  39. David Roy says:

    Jim,

    Sounds familiar. The only exception is that you work in a private hospital while some of us work in large teaching hospitals. The one thing that is the same is the computer that manages investments. Thanks for your comment.

  40. Gas says:

    Jim,

    135 bed hospital, likely doing low risk adult cases probably can do without MD supervision (until eventually someone dies or has serious morbidity and word spreads that no anesthesiologist is employed and a nurse was fully in charge, at which point the bad publicity will likely cost the hospital $$$). I can guarantee that you do not do most NICU-level peds surgeries, or level 1 trauma cases, or liver transplants or very many heart cases.

    Having said all this, it would be almost a waste of time for MD anesthesiologists to do ambulatory cases on healthy patients. I hope we as anesthesiologists will focus more on critical care (we created ICUs, nurses created anesthesia) and only serving as a peri-operative consult service to anesthesia providers when necessary for critical cases and pain management. That is the direction of most residencies and the mindset of many young medical students and anesthesiology residents of today.

  41. David Roy says:

    Gas,

    Thank you for your comments. There is plenty of room for all of us. Yes, you said it, “we created ICUs, nurses created anesthesia” and I would say OK…..not created just first trained to do anesthesia. Your idea that someone will eventually die is funny don’t you think. Patients have complications all the time. I would doubt very seriously that nurse anesthetists have a greater incidence of morbidity than physician anesthesiologists. As a matter of fact this has been documented over and over again that nurse anesthetists are as safe and as free from anesthetic complications in the same statistical averages as anesthesiologists.

    In the level 1 trauma center that I work in we function in an anesthesia care team model. This is not the case in so many rural non-trauma hospitals that Jim represents where CRNAs are lone provider. My suggestion for my colleagues is to focus on Critical care or cardiac, pediatric or transplant anesthesia. The days when a sole anesthesiologist doing a lap chole is pretty much over. In the future, health care and its reformers will be looking at maximizing the license potential of all providers. We will see where this will lead.

    As you have indicated, most residency programs are focused on where they can maximize their potential as well. Its not the bulk of surgeries that require a fellowship level of specialization.

    I appreciate this chance for a common sense dialogue and not get caught up in big egos and power trips and guarding supposed territory arguments that I see in so many places. I leave that rankling to others because frankly I’m not interested in that kind of debate.

  42. Gas says:

    David,

    Your suggestion should be well taken by my fellow residents and those that are entering the profession with a medical school education. I would also encourage we (as anesthesiologists) take back Pain Management from PM&R/Neurology and CCM from IM/Gen Surgery… these are OUR fields of medicine that we are best trained to do. I am pleased at how many programs stress general anesthesiology residency as “peri-operative medicine”, which again we are best qualified for. We understand the medical risk factors of patients and we understand the surgery and procedures that the patients are going through. That is what we learned in medical school and our prelim year of residency. We absolutely must remain very involved in OR anesthesia since most research and standards of care are done by physicians. But let the CRNAs do what they do best, administer anesthesia to patients that we help clear for surgery.

    Both CRNAs and Anesthesiologists have been around for decades and will continue to exist but we must utilize our training and backgrounds to the best of our abilities and stop fighting with each other.

  43. David Roy says:

    AGREED

  44. Jennifer says:

    It is appauling to read the majority of these comments, who state they aren’t trying to put anyone down. CRNAs are Board Certified, Master’s prepared before they are allowed to start. Albeit the word Nurse is in their title, but through ICU experience and more education/Clinical training at a Master’s Degree level they become GRNAs, then sit for Boards to earn the C. I do not believe that any professional would argue that experience in any field does not contribute to a good practitioner. Previous blogs and comments that state it’s two years of education dim the sacrifice one makes for being a Full-Time Graduate Student (who cannot work while in school). It’s much more than two years total and basic math gets you to the answer. [4 years BSN+ 1-2minimum year(s) ICU experience + 28-30months FT Graduate CRNA program from Accredited (mostly D1 schools)] school.. ***28-30months is already longer than 2 years for the simpleton.

    I work at US News and World Reports #1 Hospital. It’s a healthy balance. There are residents who starting their training in anesthesia and have never intubated a patient on July 1st. There are attending anesthesiologists who do more research than clinical rotation. There are CRNAs that have been working there for 40years. There are anesthesiologists that lead the world with their care, who pick CRNAs to deliver the plan. Hopefully you can see my point, again, it’s a healthy respectful balance of talented, educated people. There should be no debate anymore, we are all needed. Like any genetic population diversity is better than none… Eventually all fields would end up as crabgrass…..

  45. David Roy says:

    Jennifer,
    Do I need comment?
    Thanks, and yes we are all needed.
    DG

  46. tom says:

    TK in spite of all your fancy training you need a little more schooling. I am the founder/director of a 15 person all CRNA group practicing independently in the Chicago metro region. I was the first CRNA/MDA in the USA to pioneer office based surgery back in 1983 and organize an anesthesia practice dedicated solely to that concept. Office based anesthesia has grown mightily in the last 31 years and today we perform over 20k office based cases per year. In all we have performed over 320k anesthetics( general, spinal, epidural, mac, etc…) over those 31 years with a PRISTINE record of safety(we were sued once for complications following gastroenterologist perforating colon only to be dismissed without prejudice 5 days prior to trial). Additionally by eliminating facility fees (320,000 cases x average facility fee $3000) over the last 31 years more than $900,000,000 health care dollars have been saved by our innovative efforts. That’s almost ONE BILLION dollars. Also I might add we are one of only 4 anesthesia practices in the entire country to hold our own individual JCAHO 3 year accreditation. MDAs are rightfully worried that anesthesia which was originally a nursing profession, and at over 60% of current anesthetics provided by CRNAs, with no difference in statistical outcomes(other than cost-50% more for MDA),is looking again like …well… a Nursing profession. With over 31 years of safe successful practice our story is much more than anecdotal. MDAs are aware or should be that the term “medical supervision” is a billing term created and used by CMS and has nothing to do with responsibility. Most state nurse practice acts refer to “medical direction” a term which also confers no particular liability for the surgeon since the “captain of the ship” doctrine as it relates to CRNA/surgeon died its last death in California back in 1974. The TRUTH sets everyone free!!!

  47. If a CRNA and an anesthesiologist do the same thing, then that means they should get the same pay.

    If they both get the same pay, but one happens to receive more education/learning, then either reduce the education needed for the anesthesiologist or raise the education of CRNA.

    If everything is equal, such as no difference in mortality rates, but anesthesiologists happen to have more education, then anesthesiologists win in terms of job security.

    If all the pay is the same, and an administrator wants to cut costs, he will fire CRNA’s. Especially since as studies show, there’s no difference if it’s CRNA’s or anesthesiologists.

    So in worst case scenario, CRNA’s all lose their jobs, and anesthesiologists get the same pay as CRNA’s today. Or second-worst case scenario, education/requirements of CRNA’s all brought up (or reverse for anesthesiologists) and health care becomes a bit more uniform.

    Sounds good to me!

  48. David Roy says:

    Hey Dumb,
    It does not work quite that way. “Suddenly everything is in motion” as the song goes. There is room for all of us.

  49. David Roy says:

    AWESOME Tom

  50. Dave T. says:

    I don’t know where to start. So many good points from others that have already posted. Ive been a nurse for 14 years. 9 of those years in the ICU. Im sure my years of experience are irrelevant to most on this blog. I mention my experience for a reason. On too many ocassions have I seen cocky interns walk into the ICU thinking an RN had nothing to teach them, after all they were doctors. Wrong! I have seen these same doctors perscribe lethal doses of sedatives and narcotics. I have also seen these same doctors use their “do nothing and see what happens” approach to medicine only to see patients crash and die. Please be patient as I am getting to why these examples are relevant to this thread. I completely respect the fact that an anesthesiologist has worked very hard to finish medical school. I am sure medical school and residency, and further training in Anesthesia is very difficult. That being said, doctors do not have the monopoly on knowledge. They are not the only ones that have the ability to comprehend science. I am applying to CRNA school within the next year. I cant speak about what it means to be a CRNA. I can say that if I was in Cardiac Arrest in the ICU and I had a choice between a season cardiac nurse and an intern running my code, I would want the nurse, hands down.

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