How do CRNAs/SRNAs benefit anesthesiology residents? - page 8

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   Athlein1
    Loisane,
    Thank you so very much for your informative post. We SRNAs are just plain lucky to have you on this board!
  2. by   TejasDoc
    Loisane, you had so much to say, I can't really comment on it all, so I've kind of bitten of chunks and pieces. As always, your comments were great.

    Quote from Loisane
    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'm not sure if this is totally true, and I don't think it's necessarily propaganda. I think you're right that it's something the ASA likes to say, but we'll get to that.

    Quote from Loisane
    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?
    You're right, as a group, nurses were the first to specialize in anesthesia. No arguments there. Anesthesiologists and supervisors of anesthesia care did come around later, leaving a gap where nurse anesthetists were not supervised. Having conceded this, will you concede that surgical / anesthesia care in the 21st century bares little resemblence to the surgical / anesthesia care provided during this period where there were very few anesthesiologists? That surgeries and anesthesia have become increasingly complex and that while yes, anesthesia is safer now than it has ever been, it is not because the anesthesia itself has gotten easier, but because we know so much more now than we ever have.

    Quote from Loisane
    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.
    These communities, these were not major metropolitan areas were they? My experience here is somewhat limited, having lived in many cities over the course of my life, but having spent the vast majority in cities with a population over 1 million. So here is my question regarding this statement, do communities that are served only by CRNAs choose this? Or are they unable to attract an anesthesiologist, but if they could they would? Are there hospitals that only have CRNAs practicing as a matter of hospital policy? Do they turn away physicians because they choose not to utilize anesthesiologists for anesthesia services?

    Quote from Loisane
    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.
    From what I've read, this is right, no state laws or nursing boards require a CRNA to be supervised by an anesthesiologist. But I am also under the impression that many states require a CRNA to work under the direction/supervision of a physican/podiatrist/dentist ... is this correct? And as far as I've been able to find, these requirement are not about reinbursement, not at all.

    Quote from Loisane
    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.
    There's a fortune to be made in anesthesia if you follow all the rules too. I just cannot imagine that the ability to bill for things you may not actually have done, and make a fortune doing so, factored that much into what medical students chose to be their medical specialty. I consider myself about run of the mill when it comes to my knowledge of how physicians get paid to do what they do, at least at my level of training. And I know just a little more than NOTHING. I know anesthesiologists make a good living, and they have a comfortable lifestyle (so do dermatologists, radiologists, ophthamologists, plastic surgeons). Anymore than that, and I'd just be guessing. The unscrupulous ability to make money never once factored into my decision.

    Quote from Loisane
    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.
    This may change I guess if being the 'physician of record' has only something to do with reimbursement, and nothing to do with state regulations regarding physicians supervising CRNA care. Assuming this is true, in those states, where the surgeon is the supervising physician, how does his/her liability not increase?

    Quote from Loisane
    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.
    Not anesthesiologists, but physicians ... I think. And at the VERY LEAST, is it not a stretch to say that in those states where supervision by a physician is require, should that physician not be an anesthesiologist?

    Quote from Loisane
    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.
    I never said you were a cracker jack nurse or anything like it. I do believe this though, too much emphasis is placed on the history. It's used too much like a professional qualification, which it is not. It is very true that if you go back 100 years, you will be hard pressed to find yourself a physician specializing in anesthesiology and you would find an abundance of nurse anesthetists. But, I think you will also admit that there are many things that were done a 100 years ago in medicine that we would never do in a million years today ... we just know better now.

    Quote from Loisane
    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.
    Don't apologize ... if nothing else, I learned something about medicare billing. Really great post overall. I guess this is what I meant by 'legislate', and maybe I just used the wrong term. I think anesthesiologists do not see themselves as having issues with supervision, scope of practice, what some states will let them do and what other states won't, what some hospitals say they can do, and what others say they cannot, how they can bill medicare, etc. Let's just call these 'practice priviledges' to make it easy. I also don't think anesthesiologists have issues with how much they're paid compared to CRNAs, they as a general rule, make more. So this is how I think anesthesiologists might see it, and I'm really only guess here (honestly) ... they see it as though CRNAs want the 'practice priviledges' and pay of a anesthesiologist, but instead of going back to medical school and doing a residency, they lobby to have Medicare rules changed, and lobby changes in policy, such as those regarding office based anesthesia, like in Florida (I think).

    Anyway, I'm getting so tired, it's hard to keep my head from hitting the keyboard. Trying to make a cohesive argument is getting to be more effort that I'm really interested in trying to expend. If my post was off in some way, I'm going to blame it on sleep. Ask me tomorrow, I can try to clarify. Thanks for engaging me on the issues, I'm enjoying the discussion.

    TD
  3. by   gaspassah
    That surgeries and anesthesia have become increasingly complex and that while yes, anesthesia is safer now than it has ever been, it is not because the anesthesia itself has gotten easier, but because we know so much more now than we ever have.
    this statement is right and wrong. the reason anesthesia became so safe had nothing to do with anesthesiologists and supervision, but advances in drugs used ie more cardiac stable meds, monitoring equipment etc. at one time there were no pulse oxs, no ekg, all you had was a blood pressure cuff, your finger to palpate the pulse, and you looked into the patients eyes to try and determine anesthesia plane by pupil size. please do not try to say anesthesiologists were the saving grace of safety in anesthesia care, it just aint so.
    I am also under the impression that many states require a CRNA to work under the direction/supervision of a physican/podiatrist/dentist
    only in the sense that someone has to "order" the anesthesia. these doctors are not responsible nor are they involved in the delivery or liability of the anesthesia care.
    This may change I guess if being the 'physician of record' has only something to do with reimbursement, and nothing to do with state regulations regarding physicians supervising CRNA care. Assuming this is true, in those states, where the surgeon is the supervising physician, how does his/her liability not increase?
    the surgeons have no liability related to anesthesia, this has been shown through countless lawsuits. they operate we anesthetize. they are the doctor of record only to the sense a physician had to "order" (for a lack of a better word) that someone anesthetize the patient. at least this is how it was explained to me.
    Not anesthesiologists, but physicians ... I think. And at the VERY LEAST, is it not a stretch to say that in those states where supervision by a physician is require, should that physician not be an anesthesiologist?
    see above 2 posts, i know it's hard to believe but states do not require your services. this is not meant to be ugly but true. the delivery of anesthesia does not have to involve mdas. i know what you THINK is important but law does not agree with you.
    they see it as though CRNAs want the 'practice priviledges' and pay of a anesthesiologist,
    what priviledges are you taking about. the priviledge of practicing anesthesia. anesthesia again is not the sole domain of the anesthesiologist. law has shown it is the practice of both nursing and medicine.
    again i think this whole argument boils down to a couple of things.
    1 mdas think anesthesia belongs to them, no changing your mind you are what you are.
    2. IF they have to work with CRNAs then they feel they must supervise.
    again you cant change what dont want to be changed.
    3. mdas feel a threat to loss income from crna competition, fair enough
    4. crnas have and do practice safe anesthesia everyday without input from mdas and without bad outcomes.
    5 crnas are not mda wannabees. if i had wanted to be a doctor i would have.
    you can see the difference in care provided by each person. i'm not saying better just diff.
    but i cant say anything better than loisanne, i'm sure she will respond and clarify, and correct me. i just felt a need to respond to some of these questions.
    d
    Last edit by gaspassah on Jun 18, '04 : Reason: clarification
  4. by   georgia_aa
    Quote from gaspassah
    this statement is right and wrong. the reason anesthesia became so safe had nothing to do with anesthesiologists and supervision, but advances in drugs used ie more cardiac stable meds, monitoring equipment etc. please do not try to say anesthesiologists were the saving grace of safety in anesthesia care, it just aint so.

    d
    This is perhaps the most absurd statement that I've seen written on this forum to date. How did all of these wonderful advances you mentioned happen?? Was it through the ground breaking research done by CRNAs?? No, these things are developed largely by anesthesiologists and other physicians working in consort with the companies that fund their research. Do you think a drug company just comes up with an idea, develops the drug on their own, gets FDA approval and then it just lands in your anesthesia cart so that you can continue your proud 100 year tradition of safe anesthesia care?

    I work side by side everyday with an anesthesiologist responsible for most of the early animal studies on Fentanyl. Another on our faculty was instrumental in developing Milrinone. Another brilliant young cardiac anesthesiologist is fast becoming famous for ground breaking work he is doing in the area of coagulation issues during CPB. The BIS monitor was largely developed thru work done by another one of our attendings - and on and on and on....

    How many discoveries that change the way we practice anesthesia everyday have come from the CRNA camp?? How many CRNAs have secured NIH grants for their research?? You get my point??
    Last edit by georgia_aa on Jun 18, '04
  5. by   jwk
    Quote from gaspassah
    this statement is right and wrong. the reason anesthesia became so safe had nothing to do with anesthesiologists and supervision,
    The statement was absolutely CORRECT. He didn't say anything about supervision, did he? He said it's because we know so much more than we used to. It's a simple statement - one has to wonder why you read so much else into it.
    Last edit by NRSKarenRN on Jun 18, '04
  6. by   Hellllllo Nurse
    u-r-sleeepy,

    I was interested in your views and what you had to say, until this point in your post:
    Quote from u-r-sleeepy
    democraps
  7. by   loisane
    Quote from gaspassah
    but i cant say anything better than loisanne, i'm sure she will respond and clarify, and correct me. i just felt a need to respond to some of these questions.
    d
    Gaspassah has done a pretty good job.

    I'm in a rush right now. TD has asked some thoughtful questions, that deserve some thoughtful answers. But I will be back to elaborate when I can, and see if anyone is still interested ;-)

    loisane crna
  8. by   susanna
    Quote from georgia_aa
    This is perhaps the most absurd statement that I've seen written on this forum to date. How did all of these wonderful advances you mentioned happen?? Was it through the ground breaking research done by CRNAs?? No, these things are developed largely by anesthesiologists and other physicians working in consort with the companies that fund their research. Do you think a drug company just comes up with an idea, develops the drug on their own, gets FDA approval and then it just lands in your anesthesia cart so that you can continue your proud 100 year tradition of safe anesthesia care?

    I work side by side everyday with an anesthesiologist responsible for most of the early animal studies on Fentanyl. Another on our faculty was instrumental in developing Milrinone. Another brilliant young cardiac anesthesiologist is fast becoming famous for ground breaking work he is doing in the area of coagulation issues during CPB. The BIS monitor was largely developed thru work done by another one of our attendings - and on and on and on....

    How many discoveries that change the way we practice anesthesia everyday have come from the CRNA camp?? How many CRNAs have secured NIH grants for their research?? You get my point??
    I'd like to know more about these things too if anyone can answer.
    This is really an alarm to me because I thought anyone who was willing to do research and quality improvement, could.

    It was my understanding that biochemists, pharmacists, chemists, and biomedical engineers were the ones who "invented" safer drugs, techniques, and machines with the collabortion of research-focused doctors and nurses and that teams of both nurses and doctors were involved with clinical studies and statistics of these medical inventions.

    I guess this merits a whole 'nother thread on what nurse anesthetists can do in research or if they can even do research. But I thought that they were able to conduct research too? I mean, personally, I want to be a CRNA someday and if I see that a problem/question comes along in my work area that I think merits research, I think I'd like to be an active participant in solving that problem. I don't want to just sit on my *** and not do/say anything about something I know about. Does this mean that I can't?
  9. by   zentuit
    Quote from susanna
    I'd like to know more about these things too if anyone can answer.
    This is really an alarm to me because I thought anyone who was willing to do research and quality improvement, could.
    according to AANA website CRNA's are involved in research. Go to that link and look for the Research sub-heading toward the bottom of the page.

    tom
  10. by   gaspassah
    Do you think a drug company just comes up with an idea, develops the drug on their own, gets FDA approval and then it just lands in your anesthesia cart so that you can continue your proud 100 year tradition of safe anesthesia care?
    well yeah i did. drug companies with and without input from physicians work everday to improve the safety and efficacy of the drugs they produce.
    what i gather from your rather terse and somewhat inflamatory statement is that without anesthesiologists imput there would be no advance in anesthesia practice or drug safety. who is more absurd.
    any company worth their stock price knows "if you make it they will come". make a better volatile agent and people will buy it. make a more stable safe narcotic and people will buy it. i'm sure there is plenty of research by chemist and pharmacologists that are trying to improve drug safety and efficacy without the tutelage of a mda.


    That surgeries and anesthesia have become increasingly complex and that while yes, anesthesia is safer now than it has ever been, it is not because the anesthesia itself has gotten easier, but because we know so much more now than we ever have.
    read loisannes post then the rest of td's reply.
    this statement was in response to loisanns statement that crnas have been performing anesthesia for 100 years without mda supervision. td has made it clear that he believes that anesthesia is the practice of medicine and that crnas should be supervised. i took his statement to mean that as mdas they now believe and "know" that safe anesthesia is to be provided by mda supervised groups. which i disagree with. and that surgeries are more complex now requiring supervision by a mda.... again a statement i would disagree with. if i took this out of contex so be it i apologize. if not i stand by my statements. as absurd or wrong as you aa's believe them to be.
    d
    Last edit by gaspassah on Jun 21, '04 : Reason: edit wording
  11. by   TejasDoc
    Quote from gaspassah
    this statement is right and wrong. the reason anesthesia became so safe had nothing to do with anesthesiologists and supervision, but advances in drugs used ie more cardiac stable meds, monitoring equipment etc. at one time there were no pulse oxs, no ekg, all you had was a blood pressure cuff, your finger to palpate the pulse, and you looked into the patients eyes to try and determine anesthesia plane by pupil size. please do not try to say anesthesiologists were the saving grace of safety in anesthesia care, it just aint so.
    So I'm not really sure, what was wrong with that statement that made? I said absolutely nothing about anesthesiologists or supervision, not a thing. All the things you wrote about have to do with increased knowledge, which is exactly what I was talking about. BUT, since you brought it up. While I can't prove that anesthesiologists are not the reason why anesthesia is so much safer now than 100 years ago, I would be surprised if you can prove that is was NOT anesthesiologists. Like I said, I can't prove it, but I could put forth some arguments that would support the possibility. Anyway, I just had to chime in and say that you're putting words in my mouth or you're not reading my posts carefully enough. Either way, if you're going to call me out about something I've said, I should have said it.

    Quote from gaspassah
    only in the sense that someone has to "order" the anesthesia. these doctors are not responsible nor are they involved in the delivery or liability of the anesthesia care.
    Why is the word 'order' here in quotes? Does someone actually have to put an order in the chart for anesthesia services to be provided in the states that require physician supervision? Is that the only involvement that they have? If they have to put an actual order in the chart, then I don't understand why 'order' would be in quotes. AND, if they have to put an order in the chart, then I don't understand how they're not liable if something goes wrong and it is determined that anesthesia was at fault. If I'm in the ICU, and I write an order for a dopamine drip, and it is later determined that the dopamine drip killed the patient, I'm screwed. And I wouldn't have administered the drip, the ICU nurse would have administered the drip, but I wrote the order ... sooooooo. But maybe it's a different kind of order, I don't know.

    Quote from gaspassah
    the surgeons have no liability related to anesthesia, this has been shown through countless lawsuits. they operate we anesthetize. they are the doctor of record only to the sense a physician had to "order" (for a lack of a better word) that someone anesthetize the patient. at least this is how it was explained to me.
    I don't think we can throw around the word 'order' unless we're talking about a medical order from a physician, as we all know it. From our point of view as health care professionals, physician orders have a very specific meaning, if this isn't the right word, we need to find out what is the right word.

    Countless lawsuits ... but not just lawsuits, countless lawsuits ... so, I need a lawsuit to use as a reference. Just one, something I look up, something that is a matter of record in a court of law here in the United States. What would be even better is the precedent setting case in this matter. But since there are countless numbers of them, any really juicy one will do, but I need a real point of reference.

    Quote from gaspassah
    see above 2 posts, i know it's hard to believe but states do not require your services. this is not meant to be ugly but true. the delivery of anesthesia does not have to involve mdas. i know what you THINK is important but law does not agree with you.
    I'm glad you also find it hard to believe that all states do not require the services of an anesthesiologist for the provision of anesthesia care. Whew, I didn't think we'd agree on anything. :> Actually, I'm getting the distinct feeling you're not reading my posts. To be totally honest, I don't care. Read my posts, don't read my posts, save 'em, burn 'em, whatever. But if you're going to argue with me about issues that I've already commented on, at least make sure that you're quoting me properly. I didn't say that the states required anesthesiologist supervision, I said some states require PHYSICIAN supervision, and then asked if a physician is in a position to supervise anesthesia care, shouldn't that physician be an anesthesiologist. Now I've said it twice.

    Quote from gaspassah
    what priviledges are you taking about. the priviledge of practicing anesthesia. anesthesia again is not the sole domain of the anesthesiologist. law has shown it is the practice of both nursing and medicine.
    again i think this whole argument boils down to a couple of things.
    1 mdas think anesthesia belongs to them, no changing your mind you are what you are.
    2. IF they have to work with CRNAs then they feel they must supervise.
    again you cant change what dont want to be changed.
    3. mdas feel a threat to loss income from crna competition, fair enough
    4. crnas have and do practice safe anesthesia everyday without input from mdas and without bad outcomes.
    5 crnas are not mda wannabees. if i had wanted to be a doctor i would have.
    you can see the difference in care provided by each person. i'm not saying better just diff.
    but i cant say anything better than loisanne, i'm sure she will respond and clarify, and correct me. i just felt a need to respond to some of these questions.
    Ok, it's decided, you're not reading a thing I'm writing. I actually wrote out a list of things and said "Let's just call these 'practice priviledges' to make it easy." So why did you ask what I was talking about? I spelled out specifically what I was talking about and called the group of things I was talking about 'practice priviledges'.

    So your post was really just jumping down my case about a bunch of things I didn't actually say. Please let me know if you find those cases, I think they'd make interesting reading.

    Quote from loisane
    Gaspassah has done a pretty good job.
    Nope, he didn't, he actually did a very bad job. Loisane, you do such a good job posting, your comments are well thought out and well articulated. I'm going to agree with gaspassah on this one and say you've got him beat.

    TD
  12. by   gaspassah
    i read your posts. i may read into your posts, for that i apologize. however i will attempt to justify my comments.

    Originally Posted by Loisane

    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?

    origninally posted by tejasdoc

    You're right, as a group, nurses were the first to specialize in anesthesia. No arguments there. Anesthesiologists and supervisors of anesthesia care did come around later, leaving a gap where nurse anesthetists were not supervised. Having conceded this, will you concede that surgical / anesthesia care in the 21st century bares little resemblence to the surgical / anesthesia care provided during this period where there were very few anesthesiologists? That surgeries and anesthesia have become increasingly complex and that while yes, anesthesia is safer now than it has ever been, it is not because the anesthesia itself has gotten easier, but because we know so much more now than we ever have

    i took this to mean that you think anesthesia i much different now in technique as well as delivery. included in this new delivery is the mda model. you have stated earlier that you think crnas should be supervised, i take this to mean that you feel this is a safer method. so when you state we know more now (mdas supervision delivers safer care, better drugs etc. as a whole.) that supervision is important because surgeries are more complex now. again i apologize if this was not the gist of your comment. and if it is not do you believe that a crna can provide quality safe anesthesia outside of the mda supervision model?

    as for legal references:

    Landmark decisions in Kentucky (1917) and California (1936) established that nurse anesthetists were practicing nursing, not illegally practicing medicine.

    In Hughes v. St. Paul Fire and Marine Insurance Company (1981, Louisiana), a physician (who was not a surgeon) instructed a CRNA to attempt nasal intubation on a patient suffering a respiratory crisis. The court found that the doctor was not vicariously liable for the acts of the CRNA since (1) the CRNA was not employed by the doctor, and (2) the doctor did not actually supervise or control the acts of the CRNA.

    In Kemalyan v. Henderson (1954, Washington), the court found that the surgeon was not responsible for the negligence of a nurse anesthetist in administering an anesthetic since the surgeon "did not exercise any supervision or control" over the nurse anesthetist.

    In Sesselman v. Muhlenberg Hospital (1954, New Jersey), the court found that an obstetrician who gave instructions to a nurse anesthetist, did not become liable for the negligence of the nurse anesthetist.

    In cases of this type, courts sometimes impose "primary liability" rather than "vicarious liability" upon the surgeon. The courts find that the surgeon fails to take appropriate action to remedy or minimize harm when there is an anesthesia accident without regard to his responsibility for the actions of a nurse anesthetist or anesthesiologist.

    Thus, in Schneider vs. Albert Einstein Medical Center, noted above, (which involved an anesthesiologist) the court also found that the surgeon was negligent in fulfilling his obligation to monitor the patient "regardless of what the anesthesiologist is doing." The court noted that the doctor "could have and should have given orders to cancel the anesthesia attempts when it was apparent that the progress of these procedures was not satisfactory."

    Although we do not claim to have read all of the cases, we have not yet come across a case in which a statutory requirement of supervision was the basis of imposing liability on a surgeon for the actions of a nurse anesthetist. In general, it seems that the courts take a "common sense" approach to the issue by finding liability where the surgeon caused or could have prevented the damage either because of his control or because he failed to take remedial measures.

    in regard to the "order" reference, a crna is not going to walk into a patients room and put them under general anesthesia. if a dentist wants to use a crna he/she will contract a crna to do it and then ask that crna to perform anesthesia this is the order part. i did not mean that the surgeon orders anesthesia on an order sheet. i think the difference is when a nurse is performing an order in the icu it's a direct action based on the doctors order. anesthesia i guess is more of a consultation for service. i could be wrong, it's been known to happen.

    as for rights and priviledges i read your posts and this is all i found:
    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.
    CRNAs want the 'practice priviledges' and pay of a anesthesiologist, but instead of going back to medical school and doing a residency, they lobby to have Medicare rules changed, and lobby changes in policy, such as those regarding office based anesthesia, like in Florida (I think).
    so....yeah i need a list, spell it out, make it plain for me, or make it easy for yourself, give me the post number, i'm sorry just couldnt find it. if you mean coming up with differential diagnoses, interpreting labs etc, i dont think this is what crnas are out to do. if a patient in the icu desats the nurse should try to diagnose what's wrong before calling the md. ie mucous plug, migrated tube, worsening pulmonary function. there may be nursing interventions that can be made, if not then page the doc. i see this as it applies to anesthesia also.
    there are a lot of times here when i feel sad that words do not show tone or inflection of voice. not once did i post anything in response to your comments that i felt was jumping on you, if you felt that way i'm truly sorry. i was just making point counter point.
    as for the aa's i always feel like i get a little hostility, so sometimes i return it. that is immature on my part. i know that when you are in the minority in certain situations many things appear hostile. i will also agree there has been hostility in these threads and i for one will attempt to cease any hostile remarks. as adults i think we can have open frank discussions.
    so formally, if anyone has taken any of my remarks prior to this point as hostile whether i meant them to be or not,
    I apologize. please do not take this as a sign of weakness on my positions because it is not. however my grandmother would shame me for my manners at times.
    so this is how i leave it for now. floor open for more discussion.
    david student of anesthesia and of life.
    :chuckle
  13. by   susanna
    Exactly what is everybody arguing about? I'd have to go back and read more carefully to get the jist of the argument here I guess but I'm too tired to do that.

    Anyways, thanks for redirecting me, zentuit. I kind of posted right after I saw georgia aa's message without thinking because it immediately alarmed me. I forgot that this is a debate.

    About the debate: I appreciate debates A LOT and arguements and like reading them. BUT, I hope we're all on the same page here that the best anesthesia provider is the person who strives to and who is able to provide the best anesthetic care, regardless of educational title? We're all in the same boat, even the same legal boat: Everyone in anesthesia is going to have to deal with lawsuits, no matter how good you are or what kind of education you received, this field and this country is just law-suit frenzy filled. That AAs, MDAs, and CRNAs all share the same love for the same field and for the anesthesia community? That we all contribute and sacrafuce equally to the field and that it is useless to say that someone gave more? That, no matter what field you're in, there are going to be people who trying to shove other people around and make other people feel unworthy but that the truly dedicated professionals don't engage in that kind of egotistic rivalry. I hope most people here share most of these perceptions. The personal attacks in some of these posts give me the bad feeling that we really do not.

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