How do CRNAs/SRNAs benefit anesthesiology residents? - page 7

I was searching for information on the Wake Forest CRNA program and happened upon this information on the Wake Forest anesthesiology program. Dr. Royster has an interesting view on how CRNA's/SRNAs... Read More

  1. by   TejasDoc
    Quote from TennRN2004
    On the issue of going back to school for CRNA vs. MDA I can 100% tell you why my choice is to stay in the nursing profession and not become a MDA. Let me start by saying We do have a med school about 2 hours from here and if I decided that was what I wanted to do, then yes my husband and son would move and sacrifice and struggle to see me go to med school. However, I choose not to do that because the entire philosophy of medicine and nursing have different fundamental assumptions. I believe the nursing philosophy and base my practice on the following.

    I was told repeatedly in nursing school "medicine is the study of treating disease, nursing is the study of how the disease affects the person". Nursing has a wholistic approach to patient care. When I walk in a pts room I see the interactions between the patient, the disease, the family- it is all interconnected and must be considered as I provide care. MOST (I stress most) docs go into the room and do not care about anything but the heart or lung and do a minimal assessment of the pt at best. Some don't do an assessment at all, but look at the nurses notes and copy what the nurse charted about the pt. The doc walks in the room and says "I'm DR. ______..." and has usually a formal unequal relationship where the doctor is in control and the pt is dependent upon the doctor. I as a nurse walk in and within a few minutes I'm on a first name basis with the pt, the spouse, and whoever else is in the room.

    Just this week I can give you a few experiences I've had that make me want to stay in nursing by being a CRNA. One of my pts is brain dead on the vent, with absolutely no chance of recovery. The docs come in and tell the family this and then walk out. It is the nursing staff who explains all the medical jargon, why the pt will not recover, and deal with all the tears and emotions the family has. In another room, one of my patients is dying from cancer, and we feel the pt won't make it through the shift. We call the family they are out of town but on their way. I as the nurse go in to comfort the patient, hold the pts hand until the family gets there. Now I ask you, how many doctors do you see who have this much interaction with the pt? Most I know would be above holding a dying pts hand. Again, I am saying most, not all.

    Your professional education teaches you (if I'm wrong here correct me) in a philosophy that makes you distant from human interactions between you and the pt. Pts become "the heart in bed 7". My professional education teaches me that the human interaction is the basis of my existence as a nurse. I am constantly watching, observing not only the pts medical condition, but helping emotionally as well. If I chose to and become a MDA, I would miss this essential link between me and the pt, because as a doc, I would think in terms of "treatment" and compartamentalize the pt.

    I LOVE my job and I go home and everyday and know I've made a difference. Why? Because I feel good about what I do, but also because the pt and families tell me so. Now, I know that docs do make a difference as well, but who does the patient know and have a closer relationship with?

    So, I have a question for you now. I want to know honestly if you think being a MDA is superior to being a CRNA? Why? I know there is the supervision thing you have that CRNAs must be supervised by MDAs. (I wonder though if they really need supervision or if it is similar to how I think on nurse practioners in that FNPs are fully capable of treating and writing prescriptions. But they have to be cosigned in most states by a MD. Now why is this? Maybe it is because docs want to keep that power over us (nurses) because if all of a sudden we can do something independent without them then the MD profession is threatened by us. I am not being bitter here, that is just my oppinion from what I've seen in clinical areas.) So, do I think CRNAs need supervision? Absolutely not. If they do, then why are there rural areas where CRNAs are the only anesthesia providers for 100 miles as you said earlier. We are capable of being independent, but I think that very independence threatens your profession, and so you want to think we need to have you supervise for your own security.
    TennRN2004,

    I agree with you, it is a struggle and a sacrafice for the families of physicians in training ... my spouse would be more than happy to tell you all about it.

    As for anesthesiologists being superior to nurse anesthetists ... I have to be very careful with this, 'cause if I breathe the wrong way, somebody is going to be offended. I think an anesthesiologist receives superior training when applied to the practice of anesthesia.

    It sounds like the physicians you work with don't try very hard to have meaningful relationships with their patients. I don't really know what to say about that, except that we're not training to be that way. As for physicians not examining their patients on rounds and using your assessment. It's one thing to use your assessment of vitals, it's another to just copy "III/VI holosystolic murmur best heard in the axillary line". BUT, nurses get lazy too, how many times have I read that a patient's respiratory rate is 20? Do you know what kind of **** storm I would hear if I pulled a nurse aside to explain that 20 wasn't normal?!

    I appreciate you explaining your training to me, and how you approach patients. I can tell there are even differences in the terminology we use, I don't say 'assess', I use the word 'examine'. You and I have to approach patients differently, my paradigm is one of diagnosis and treatment, and this is where I think my training is superior when applied to the practice of anesthesia. All of my training is suposed to be able to prepare me to recognize the signs of pathophysiology, whether that be through examination or interpretation of tests and labs, and make a differential diagnosis or a definitive diagnosis. If I have a differential, I must decide what options are available for me to attain a specific diagnosis, weigh the pros and cons, and decide what tests/exams/studies I should order. I have to be able to interpret these and then come up with a treatment plan. This is what happens in the OR, but it's a critical care setting and very acute. If for example, I see that a patient is hypoxemic. I have to decide why --> e.g. make a diagnosis. If I can't, it becomes my job to narrow down the differential through interventions, tests, or examination. Once I have a diagnosis, I need to treat, otherwise, what was the point of figuring out why? This is why I see anesthesia as a medical profession, one of diagnosis and treatment.

    In addition, my clinical anesthesia training is longer and encompasses a wider range of care, including the ICU. If I choose, I may receive advanced subspecialty training in many fields as well, further expanding my body of knowledge and experience. As far as I know, the option to fellowship train in anesthesia subspecialties does not exist for CRNAs.

    Anyway, I hope this kind of answers your question. I think I was long winded, and may or may not have made the point I was trying to. I just didn't think I could say that I thought my training was superior, and then not say why.

    TD
  2. by   deepz
    [QUOTE=TejasDoc] .... childish things like 'A$A', but mostly because you say things that either aren't really true, or only partially true, don't ever give references ....[ ]

    Ad hominem. 'Always' this and 'never' that. You this, you that.

    When unable to reason your way out of a paper bag, then forge personal attacks. Call them names. Angry. Childish. ... Whatever, doctor. I don't need your approval. I only point out that the emperor's got no skivvies.

    Such behaviors are very familiar to me, having dealt with physicians most of my adult life. A complication? Must be the patient's fault, not mine. Attack, attack. As TennRN points out, how different are the behaviors typical of MDs from those typical of RNs. Has a lot to do with the historical success of CRNAs.

    Originally it seemed as if you came to this nurses board to learn, doctor. But instead you came to beat your chest, didn't you? Are we impressed? We've seen others like you come and go. Fact is, this CRNA BB doesn't need supervision.

    deepz

    When you're in a hurry, take the long way.
    ---- Japanese proverb
  3. by   TejasDoc
    [QUOTE=deepz]
    Quote from TejasDoc
    .... childish things like 'A$A', but mostly because you say things that either aren't really true, or only partially true, don't ever give references ....[ ]

    Ad hominem. 'Always' this and 'never' that. You this, you that.

    When unable to reason your way out of a paper bag, then forge personal attacks. Call them names. Angry. Childish. ... Whatever, doctor. I don't need your approval. I only point out that the emperor's got no skivvies.

    Such behaviors are very familiar to me, having dealt with physicians most of my adult life. A complication? Must be the patient's fault, not mine. Attack, attack. As TennRN points out, how different are the behaviors typical of MDs from those typical of RNs. Has a lot to do with the historical success of CRNAs.

    Originally it seemed as if you came to this nurses board to learn, doctor. But instead you came to beat your chest, didn't you? Are we impressed? We've seen others like you come and go. Fact is, this CRNA BB doesn't need supervision.

    deepz

    When you're in a hurry, take the long way.
    ---- Japanese proverb
    Like I said before, not a comment about things you said that weren't actually true, or only partially true, just attacks on me.

    You're right, I called you childish, and I even gave reasons why. Everyone else can decide if they agree or disagree.

    And I did come here to learn, and it's been a pretty informative lesson so far. If nothing else, I've learned to always check whether or not the stuff you say is actually true, and that really makes it all worth it in the end. The things I've learned just fact checking you has been impressive - thanks for the education.

    Chest beating? Come on. Are you talking about my comments about supervision and superior training? I was asked those questions specifically, if people didn't want my opinion about those things, they shouldn't ask. I didn't bring those things up, and I didn't come to this discussion to have those conversations. But I think people ask because they knew what I would say, and that's what they wanted me to say. Everyone needs a villain.

    And the "... this ..., doctor", "... that ..., doctor" is getting old already, but if you say it a million times, I could see if the ASA would send you a set of steak knives.

    TD

    Instead of looking up catchy proverbs on the web, one should check their facts.
    ---TejasDoc Internet Proverb
  4. by   jwk
    Quote from deepz

    Early in your training for your career, as you apparently are, one might hope you'd be more open to multiple viewpoints and less accepting of the A$A boilerplate. Much of their BS doesn't stand up to examination, even so basic a point as 'ASA, since 1905.' Typical exaggeration. Incorporated in 1937. But they needed something to pre-date the AANA in 1931. Oneupmanship, ego-driven, what do we call it?

    ?
    So all I hear is how CRNA's have been doing this for over 100 years, yet the AANA was incorporated in 1931? Hmmmmmmmmmmm....

    And as far as "early in your training...one might hope you'd be more open to multiple viewpoints..." How many student nurse anesthetists on this board get on the "bash the MDA, ASA, and AA" bandwagon? Some of the posters aren't even finished with nursing school, much less anesthesia school, and have already been indoctrinated. And I'm so tired of hearing "you shouldn't get on this board if you don't want a pro-CRNA viewpoint". An opinion is one thing - statements that sometimes border on libelous are entirely another.

    I understand the bias, but can you at least be civil about it? loisanne, user69, kmchugh, and others at least engage in a more adult manner of discourse, even though TD and I and others may disagree with them.
    Last edit by jwk on Jun 17, '04
  5. by   CougRN
    Quote from jwk
    So all I hear is how CRNA's have been doing this for over 100 years, yet the AANA was incorporated in 1931? Hmmmmmmmmmmm....

    And as far as "early in your training...one might hope you'd be more open to multiply viewpoints..." How many student nurse anesthetists on this board get on the "bash the MDA, ASA, and AA" bandwagon? Some of the posters aren't even finished with nursing school, much less anesthesia school, and have already been indoctrinated. And I'm so tired of hearing "you shouldn't get on this board if you don't want a pro-CRNA viewpoint". An opinion is one thing - statements that sometimes border on libelous are entirely another.

    I understand the bias, but can you at least be civil about it? loisanne, user69, kmchugh, and others at least engage in a more adult manner of discourse, even though TD and I and others may disagree with them.
    jwk, just to clarify. the aana was formed in 1931. that does not mean that nurses were not trained to perform anesthesia before that.

    although documentaion of nurse anesthesia roots are sketchy prior to 1877 it is well documented that nurses were trained to perform anesthesia and oversee all anesthesia duties at certain hospitals in 1877. In 1889 wtih help of Dr. Willam W. Mayo nurses began being trained to perform anesthesia in Rochester. So this is were the 100 years of service comes in to play.

    now i'm not trying to say anything about your training or history. just trying to set the record straight so that you know where this comes from when it is stated on this board.
    Last edit by CougRN on Jun 17, '04
  6. by   deepz
    Quote from TejasDoc
    .........
    Instead of looking up catchy proverbs on the web, one should check their facts.
    ---TejasDoc Internet Proverb

    My local potter friend Chyako Hashimoto will be disappointed to learn of your high esteem for her favorite proverb from her native village of Mashiko.

    Really, doctor, your snottiness titer has approached levels high enough to qualify you for an AA. Don't make us medicate you!

    All due respect.
  7. by   loisane
    Quote from TejasDoc
    If you want to practice anesthesia with the rights, priviledges, respect and recognition of an anesthesiologist, go to medical school and finish a residency in anesthesiology. And if you want to be a CRNA, with all the rights, priviledges, respect and recognition of a CRNA, by all means, good luck, it's a worthly and impressive goal also. But to me, it seems wrong, if you train to be a CRNA and then try to legislate your way to being treated like an anesthesiologist.
    I know you are engaging multiple conversations, but there is part of your post I simply must respond to. As always, I am offering the truth as I see it, and encourage all to do their own research, which I feel will validate these facts.

    Believe me when I tell you that my response is motivated by passion, and not anger. I hope you have read enough of my postings to know that. This cyberspace communication is tricky at times!

    Are CRNAs trying to expand their scope of practice through legislation? The answer is an emphatic NO. This line is pure ASA propaganda. Here is my reasoning.

    I don't think there is any disagreement that nurse anesthetists were the first health care professionals to specialize in anesthesia. So it follows logically that nurse anesthetists "did it all" without supervision. What we need to determine is when/if did this notion of "supervision" begin?

    Many communities who now have anesthesiologists were served only by nurse anesthetists, even as recently as the 1970s. The first anesthesiologists that came to these communities were not there to supervise. They functioned as an extra resource person, what you might call a consultant. I know this for a fact in my community, because I have family that experienced this transition.

    I think it isn't a stretch to assume this is the same thing that happened everywhere. After all, all 50 state have nurse practice acts that allow CRNAs to perform anesthesia, and none require these CRNAs be supervised by an anesthesiologist. CRNAs have always been the primary hands on anesthesia provider in this country.

    Most CRNAs were employed by hospitals. For Medicare patients, hospitals get paid under part A. So part A is where they recouped their CRNA related costs.

    Physicians are paid under Medicare part B. When employment patterns started changing, and some CRNAs were no longer working for hospitals, rules were made to allow CRNAs to bill under part B as well.

    There were abuses. Anesthesiologists were contributing very little to cases, and sometimes not even in the building. Yet they billed under part B for their services. There was a fortune to be made, if an anesthesiologist was willing to be this unscrupulous. Anesthesiology became a very popular specialization.

    In the meantime, the hospital continued to bill under part A for their employed CRNAs, who had done the work. About this time there was beginning to be the call for health care reform, cost containment, etc.

    So the TEFRA rules were born. These are 7 steps that an anesthesiologist must perform in order to bill for anesthesia under Medicare part B. The rules were designed to decrease billing fraud. They NEVER were meant as standards of care. To my knowledge, there was never ANY research done that said "Oh, to be safe, we need anesthesiologists to do this and that. These just aren't things CRNAs should be doing". Instead the intent was "If you are going to charge us for a service provided, then we want documentation that you have at least contributed enough to this case to deserve that payment."

    This is our current system. If an anesthesiologist jumps through the 7 TEFRA hoops, he can bill for his services under part B for something called "medical direction". If the anesthesiologist is involved, but doesn't complete all 7 TEFRA steps, he can still collect under part B for "medical supervision" .

    The hospital can still bill for CRNAs they employ under part A. But, remember, there is no law anywhere requiring anesthesiologists be involved at all. So what about hospitals who employ CRNAs, and choose not to use the services of an anesthesiologist? Well, that is fine, and can be done.

    So what was all the bru-haw-haw about a few years ago? Part A rules included language about physician involvement as a pre-requisite for payment. Some surgeons expressed reluctance to be the "physician" of record. This was despite numerous court cases that have clearly shown that the surgeon's liability does not increase when working with a CRNA.

    AANA lobbied to get this language removed. It was just a way to appease the surgeons, and make them feel less threatened, about a system that was perfectly legal, and within policy. Personally, I believe the reaction was way out of proportion. When you have a patchwork of policies, that has evolved over time, you are bound to get inconsistencies. This was just an attempt to clean up the language, and make things more coherent.

    Remember, in the beginning, it didn't have a THING to do with anesthesiologists. No where in law or policy are CRNAs required to work with anesthesiologists. But ASA sure did paint that sort of a picture.

    It is pure ASA language to say that CRNAs are trying to increase their scope of practice through legislation. The supervision issue (which was about policy, not law), was about MAINTAINING our scope of practice. I know of NO legislation whose aim is to increase CRNAs scope of practice. We ALREADY have these rights under law. INSTEAD, what we have are legislative efforts to REDUCE our scope of practice. Florida, and New Jersey as examples.

    Of course, you have a perfect right to a belief that CRNAs have too much scope of practice, and it should be reduced. But you, ASA, or others should at least be honest about the debate. CRNAs are not asking for more, you want us to have less.

    Nurse anesthetists make a big deal about our history. As a profession, we have been doing this along time. We are not a bunch of cracker jack nurses who decided we wanted to play doctor, and tried to sneak our way into a physician specialization. It is much easier to make a case for the reverse. When you look at the big picture, one could say that it is anesthesiologists who are trying to play nurses.

    Hope you're still with me, I know this is long winded. But these are very complex issues. I recommend the book "Watchful Care" by Bankert for the history of nurse anesthesia. It has been awhile since I read it, but I am sure it would have a section of this, with references. Or, I am sure this is also in the anesthesiology literature, if a person were to dig for it.

    If you meant something different by "legislate your way to being treated like an anesthesiologist", then my appologies for this lengthy lesson. But these are important issues, all the same, and maybe someone else benefited from the summary.

    loisane crna
    Last edit by NRSKarenRN on Jun 18, '04
  8. by   versatile_kat
    ... and maybe someone else benefited from the summary.

    loisane crna


    I know I sure did!

    That was one of the most clear and concise background's into the CRNA/MDA debate I've read yet. Thank you as always, loisane, for adding your insight's. They are always appreciated.
  9. by   alansmith52
    I'd like to just copy that summary off and hand to anyone that asks me about my scope family,frieds and foes. I am getting sick of deffending my self and sounding self consious. do you think you can fit that on a buisness card
  10. by   alansmith52
    the foundation of the AANA is a silly refrence for the beggings of Anesthesia as a profession. come on now.
  11. by   alansmith52
    this forum has sure evolved. I remember back when there was less than 10 of us or so. I like the diversity now but it sure can get heated. which I also like. just an observation as to how fast these internet thangs grow. why back when I invented it...
  12. by   Pepino
    this board is a microcosm of the nursing profession. we bicker, *****, and moan with eachother--this represents the crux of the issue as to why nurses, even though there are three some-odd-million of us, can't band together for a shared purpose.

    btw, if the working conditions at a hospital affiliated with the Wake Forest residency program are insufferable, the anesthetists employed there are free to leave. Again, this thread just adds credence to the importance of minding your own business--go to work, do your job, keep your mouth shut, and go home at the end of the day.
  13. by   loisane
    Quote from Pepino
    Again, this thread just adds credence to the importance of minding your own business--go to work, do your job, keep your mouth shut, and go home at the end of the day.
    Oh, no, no, no. Don't feel like that! Get informed, get involved. It is YOUR profession. Don't just sit back, and let other people make the decisions that are going to define YOUR profession and YOUR life!

    Now, if you were talking about a coping mechanism for a less than ideal work situation, with which you are stuck because there are outside forces making it difficult to leave for another job, then--I hear ya. We've all been there. But hopefully, that is a temporary condition. And it still doesn't stop you from keeping your own mind active, gathering information, making your own opinions, and planning for a better future.

    Nurses can do this. We have to.

    loisane crna

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