Do you need an Anesthesiologist?

  1. I'm in my 2nd year of a CRNA program, with the third year still remaining. During the first year which is entirely didactic, my training was always geared towards total independence. There was never a moment the professors said, don't worry about this part, an MDA will handle it or back you up. In fact, MDAs were something we knew existed but it never changed our learning or practice. Every aspect of anesthesia was required to master, including background sciences like physiology, pathophysiology, gross dissection, genetics, general pharmacology, anesthesia pharmacology, organic chem, statistical research, business and legal aspects of anesthesia the list goes on and on.

    As I've done a few rotations at this point I've seen some different practice models. While I haven't done my rotations yet in a fully medical directed ACT or in a CRNA only practice I have classmates that are doing them now and have an idea of the workflow.

    I can't speak definitively for all CRNA programs but I do have various friends in different programs and I get the impression they are also trained to be fully independent. My confusion is when I go through rotations and see a dynamic that doesn't appear very independent. Are you independent when someone else did your pre-op assessment, Interscalene block, ordered your preop meds without asking you what preop meds you wanted for your case, coming in your room to "check on you" without being requested, assigning your ASA class, circulator asking for documentation who your supervisor is, telling your patient in preop they are going to be the "doctor" responsible for putting them to sleep..

    I've even seen situations where the patient was on a vasopressor drip with no A-line and the CRNA chose to not place one because the MDA didn't do it in preop. I had a CRNA say recently that they couldn't place a CVL because he isn't a doctor and went to a crappy school. This was said (I hope) half in jest but it was said in the OR with assistive personnel in earshot which I found appalling. At this particular facility the CRNAs aren't allowed to place their own CVL. Insulting that an anesthesia group would tell you that you can't practice a skill you were trained and licensed to perform.


    Is this Stockholm syndrome? Have these CRNAs just forgot their training or worked in an environment with an MDA around so long they forgot they were educated to perform those same tasks? Or perhaps they weren't trained as a full spectrum anesthesia provider, maybe my program is different.

    Just interested in what you practicing CRNAs think and if you believe you need an anesthesiologist to help you in your practice?

    *Caveat to this, I'm only bringing up the examples of issues I've found and not focusing on all the amazing brilliant CRNAs I've worked with who are clinically more capable than multiple MDAs I've trained under.
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  2. 9 Comments

  3. by   wtbcrna
    Quote from Bluebolt
    I'm in my 2nd year of a CRNA program, with the third year still remaining. During the first year which is entirely didactic, my training was always geared towards total independence. There was never a moment the professors said, don't worry about this part, an MDA will handle it or back you up. In fact, MDAs were something we knew existed but it never changed our learning or practice. Every aspect of anesthesia was required to master, including background sciences like physiology, pathophysiology, gross dissection, genetics, general pharmacology, anesthesia pharmacology, organic chem, statistical research, business and legal aspects of anesthesia the list goes on and on.

    As I've done a few rotations at this point I've seen some different practice models. While I haven't done my rotations yet in a fully medical directed ACT or in a CRNA only practice I have classmates that are doing them now and have an idea of the workflow.

    I can't speak definitively for all CRNA programs but I do have various friends in different programs and I get the impression they are also trained to be fully independent. My confusion is when I go through rotations and see a dynamic that doesn't appear very independent. Are you independent when someone else did your pre-op assessment, Interscalene block, ordered your preop meds without asking you what preop meds you wanted for your case, coming in your room to "check on you" without being requested, assigning your ASA class, circulator asking for documentation who your supervisor is, telling your patient in preop they are going to be the "doctor" responsible for putting them to sleep..

    I've even seen situations where the patient was on a vasopressor drip with no A-line and the CRNA chose to not place one because the MDA didn't do it in preop. I had a CRNA say recently that they couldn't place a CVL because he isn't a doctor and went to a crappy school. This was said (I hope) half in jest but it was said in the OR with assistive personnel in earshot which I found appalling. At this particular facility the CRNAs aren't allowed to place their own CVL. Insulting that an anesthesia group would tell you that you can't practice a skill you were trained and licensed to perform.


    Is this Stockholm syndrome? Have these CRNAs just forgot their training or worked in an environment with an MDA around so long they forgot they were educated to perform those same tasks? Or perhaps they weren't trained as a full spectrum anesthesia provider, maybe my program is different.

    Just interested in what you practicing CRNAs think and if you believe you need an anesthesiologist to help you in your practice?

    *Caveat to this, I'm only bringing up the examples of issues I've found and not focusing on all the amazing brilliant CRNAs I've worked with who are clinically more capable than multiple MDAs I've trained under.
    You will find good and bad Anesthesia providers no matter what their education is. You will find anesthesiologists who couldn't do an Anesthesia case anymore to save their own life, and you will find CRNAs that are happy doing nothing but sitting in an OR writing vitals all while letting the anesthesiologists make all the decisions.
    You cannot really make generalizations on either group of providers.
  4. by   offlabel
    BB, you seem like a sharp guy whose heart is in the right place. But you're getting caught up into BS that will only distract you from your training and it is a huge disservice that is being done to you. I'm not directing this at you personally, so don't take it that way.

    There is nothing more pathetic than a senior SRNA swaggering into the hospital that apparently has it more figured out than every CRNA and doc in the place that can't even put an A-line in. Or a spinal or epidural without stabbing the poor patient 8 times.

    Or blasting a patient with bad MR with phenylephrine because the MAP is falling. Or prepping some patients back for an epidural that is taking Coumadin for afib....get the point?

    Right now your job is learning my job, not getting caught up in bizarre notions of "Stockholm Syndrome" and being convinced you have everyone that is training you sized up and neatly categorized.

    Forget all of that BS for now. Learn how to do anesthesia well and then pick the kind of practice that most suits your skill and preferences. Then take on the world after you can back it up with some mad skills. Even the most fiercely independent minded CRNA will look at a person in training with more hubris than skill with great skepticism.

    BTW, you don't necessarily need an aline if you put your patient on a pressor.
  5. by   Bluebolt
    wtbcrna, I agree that there are various spectrums of anesthesia providers. I tried to note that by saying I've worked with some obviously very skilled independent CRNAs along with MDAs who take their own cases.

    offlabel, I understand your viewpoint. I actively work at staying humble during my training and remember that while I've had mountains of information shoved into my head I still have much to learn. The idealism of a padawan learner can be obnoxious to some in practice who have had reality beat them into a situation less than ideal. I'm aware that some great CRNAs chose to live near family, a city they are attached to etc and by doing that it forces them to work in a situation where they are only allowed to practice at half their licensure/training.

    What the root of my concern or question is, is an anesthesiologist what they feel they need for safe practice? I'm learning and investing much of my time with the perspective that I won't need an MDA as a safety net or backup. I'm curious if everyone started off with this focus and they just changed over time once out in practice? Or does your perspective change based on the type of practice you take a job in after you graduate? Just trying to make an informed decision on the rest of my training and perspective, along with the type of practice I seek out close to graduation.
  6. by   wtbcrna
    Quote from Bluebolt
    wtbcrna, I agree that there are various spectrums of anesthesia providers. I tried to note that by saying I've worked with some obviously very skilled independent CRNAs along with MDAs who take their own cases.

    offlabel, I understand your viewpoint. I actively work at staying humble during my training and remember that while I've had mountains of information shoved into my head I still have much to learn. The idealism of a padawan learner can be obnoxious to some in practice who have had reality beat them into a situation less than ideal. I'm aware that some great CRNAs chose to live near family, a city they are attached to etc and by doing that it forces them to work in a situation where they are only allowed to practice at half their licensure/training.

    What the root of my concern or question is, is an anesthesiologist what they feel they need for safe practice? I'm learning and investing much of my time with the perspective that I won't need an MDA as a safety net or backup. I'm curious if everyone started off with this focus and they just changed over time once out in practice? Or does your perspective change based on the type of practice you take a job in after you graduate? Just trying to make an informed decision on the rest of my training and perspective, along with the type of practice I seek out close to graduation.
    The way most CRNAs feel about needing an anesthesiologists seems to be directly related to where they were trained and how they were taught.

    My program expected us to be independent providers as soon as you graduated and passed boards. I started my first CRNA job with 2 days orientation (which was actually 1/2 day) and then within two weeks I was pulling solo call as the only Anesthesia provider in house.
  7. by   Bluebolt
    Quote from wtbcrna
    My program expected us to be independent providers as soon as you graduated and passed boards. I started my first CRNA job with 2 days orientation (which was actually 1/2 day) and then within two weeks I was pulling solo call as the only Anesthesia provider in house.
    Thank you for your open response. I appreciate a CRNAs candor on this touchy subject of autonomy and independence, especially asking as a SRNA not licensed yet. I've seen so many brilliant CRNAs working in supervised positions I was concerned that my training was putting delusional ideas in my head of independent practice.

    I usually wouldn't ask this type of question on a forum but you can imagine how defensive and offended a CRNA would respond if you asked tough questions like this during rotations. While 75 hours of my week is dedicated to studying the science of anesthesia, I can allow 30 mins to analyze the field and practice I'm working so hard to step into.
  8. by   wtbcrna
    Quote from Bluebolt
    Thank you for your open response. I appreciate a CRNAs candor on this touchy subject of autonomy and independence, especially asking as a SRNA not licensed yet. I've seen so many brilliant CRNAs working in supervised positions I was concerned that my training was putting delusional ideas in my head of independent practice.

    I usually wouldn't ask this type of question on a forum but you can imagine how defensive and offended a CRNA would respond if you asked tough questions like this during rotations. While 75 hours of my week is dedicated to studying the science of anesthesia, I can allow 30 mins to analyze the field and practice I'm working so hard to step into.
    You should definitely keep politics out of the work place. I would avoid talks of Anesthesia politics like the plaque while a student at clinicals.

    I was warned about Anesthesia politics by a CRNA before I was even in Anesthesia school. I never really understand how bad the politics are in this career field were until I graduated.
    Last edit by wtbcrna on Nov 13
  9. by   loveanesthesia
    What the root of my concern or question is, is an anesthesiologist what they feel they need for safe practice? I'm learning and investing much of my time with the perspective that I won't need an MDA as a safety net or backup. I'm curious if everyone started off with this focus and they just changed over time once out in practice? Or does your perspective change based on the type of practice you take a job in after you graduate?

    I think it's a combo with some CRNAs accepting and/or embracing the idea that ‘my attending' makes the decisions with an "I don't get paid any more to stick my neck out, so why do it." Other CRNAs just get worn down and don't want conflict on a daily basis. In some ACT practices it's damn if you do, and damn if you don't. If a CRNA is strong and independent, then some of the MDAs will be threatened and be watching for any perceived problem to point out. But if a CRNA is not independent then the MDAs will point out their perceived inadequacies. It's walking a line between not being too smart and not being too dumb. I know I've smiled and nodded when an MDA was explaining something incorrectly which I could have sited references. I let him think he's right because I didn't think there was any good in my correcting him.
  10. by   Bluebolt
    lovesanesthesia,

    I've been in those situations you mention. As far as remembering dosages, scientific concepts and theory like the Fa/Fi curve, new research, etc as a student you usually have an advantage. I assume that information will dull for myself as well as years pass unless I keep up with it. Now that boards are required to take every 8 years people will probably stay more up to date.

    I've also had CRNAs make comments about not minding someone else doing their block or CVL because they get paid the same either way and it's less work for them as well as less liability. I can't say that one day near retirement I won't be looking for the path of least resistance with bread and butter cases, working less for high pay. My plan until then is to work to the full breadth of anesthesia, providing the full spectrum of services for my patients in a safe and cost effective manner. I didn't work this hard and invest so much to do otherwise. I'm hopeful that my fellow SRNAs are of the same mind.
  11. by   bfreezy
    Great post man. Always enjoy your videos!

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