Coug
First, don't be too hard on Tenesma. He's not changing faces, and I don't see a whole lot different in this post compared to some of the things he's said here. Also, he provides good insight into many aspects of anesthesia care. Unfortunately, he suffers from MDA syndrome
where nurse anesthetists are concerned.
But, to answer your question, no, CRNA's are not the "bi***s" of MDA's. There are some things Tenesma says in that post that are quite true, while others appear true on the surface, but need a little deeper examination. Let's look at each point he made:
1. True, with a proviso. Generally, lawyers and plaintiffs see the hospital and the physician as having the "deep pockets." You don't sue poor people, there's no money in it. However, I've never seen any data to suggest that awards for malpractice are higher in cases involving MDA's over cases involving CRNA's. CRNA's insurance premiums are lower, however. Much of that is due to MDA's doing things that are outside the scope of practice of CRNA's (prescriptions, pain management surgical procedures, etc), and therefore there are more things an MDA can be sued for.
2. True on it's face. However, nurses were the first to perform anesthesia as a
specialty. Prior to nurse anesthetists, anesthesia was not performed by fully certified physicians, because the surgeon is the head cheese in the OR, and no doctor wanted to play second fiddle to another doctor. So, initially, medical students were tried out as anesthesia providers, but morbidity and mortality rates were too high. Nurses were then trained specifically to administer anesthesia. M&M rates dropped significantly. In my mind, this was the first proof that anesthesia needed to be a separate discipline. However, none of this is proof that one group is infringing on the turf of the other.
3. Well.... I work in a very rural hospital, and we have no MDA's. (And rest assured, I am
no one's bi***!) We do what are considered to be big general surgery cases (including whipples), and I do anesthesia for ASA III and IV patients routinely. As to the tertiary centers, what Tenesma said would be true if the cases were being done by MDA's. In many, if not nearly all of those tertiary centers, the anesthetic for nearly all cases, from endoscopy to open heart procedures is actually done by a CRNA under MDA supervision. Often, that supervision means the MDA is in the room only for induction. Where I was before, I did a large number of cases, including open heart and intercranial procedures essentially by myself. The supervising MDA sat in the corner while I induced the patient, inserted the necessary lines, then left to mess online with his stocks, while I did the anesthetic. Unless I paged the MD so I could go to the bathroom, the next time I saw the MDA was often in the physicians lounge after I had dropped the patient off in the PACU or ICU.
4. True enough. But then, before beginning their residency in anesthesia, new graduate doctors don't have experience with anesthesia, either. As to the hours of education, I'm presuming Tenesma is including hours in medical school. Most medical schools offer no classes in any specialty, but rather teach a general medicine curriculum. Prior to beginning an anesthesia residency, most medical students contact with patients has been very limited and highly supervised. Nurse anesthetists, on the other hand, have had at least a year of experience working directly with critically ill and injured patients. And its difficult to compare the education received by MDA's to that received by CRNA's. The education received by CRNA's is highly focused on providing anesthesia, which MDA's get none of until they actually begin a residency.
5. Exactly correct.
6. This would be true if and only if MDA's could bill at a higher rate than CRNA's. In other words, if a CRNA could bill $X for anesthesia provided for procedure A, while an MDA could bill $X + $Y for the same procedure, then Tenesma could make this statement. However, the truth is that for any procedure, the amount that Medicare or insurance companies will pay for the anesthetic for that procedure is always the same, regardless of whether the anesthetic is performed by an MDA, a CRNA, or a CRNA under MDA supervision. In other words, insurance companies and Medicare don't care who does the anesthetic.
The fact that MDA's make more than CRNA's has nothing to do with insurance companies, it has to do with what MDA run groups are willing to pay CRNA's. That's why most anesthesia groups want to hire a larger percentage of CRNA's. The last figures I read said that an anesthesia provider, working full time, could expect to bill about $200,000 - $250,000 for their services. If you ran an anesthsia group, and had to pay $150,000 to employ a CRNA, versus $225,000 for an MDA, which provider would you hire?
However, there is an interesting counterargument spawned by Tenesma's last statement. Since insurance companies pay the same for an anesthetic, regardless of who does it, perhaps they are aware that an anesthetic performed by an MDA is no safer than one performed by a CRNA. Otherwise, they
would reimburse at a higher rate for MDA's, and would demand that MDA's perform the anesthetic for certain procedures.
Kevin McHugh, CRNA
Crna = Mda?!
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