How do CRNAs/SRNAs benefit anesthesiology residents? - page 9

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   FNP2B
    i have some ? in regard to salary for CRNA's?
  2. by   NRSKarenRN
    personal attacks
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    how to handle personal attacks or objectionable material is seen
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    ignore list
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    giving all posters a chance to review tos and and rethink what they have posted on this thread. personal cleanup appreciated.
  3. by   smk1
    Quote from FNP2B
    i have some ? in regard to salary for CRNA's?
    go to www.salary.com it will give you a good idea of the salary range for a crna as it will differ the same as any job in different parts of the country.
  4. by   loisane
    Boy, I turn my back for a moment, and the moderators are in here giving us the "look"! LOL

    TD, I too was a little surprised at your reaction to Gaspassah. I guess I made some of the same assumptions that Gasspassah explained in his subsequent response to you. I think most of us are doing a fairly good job of giving and receiving feedback during this discussion.

    About history, I did take note of your early comments about putting it in perspective (sort of-yeah but what have you done lately, except you stated it much more professionally). While that was a little difficult for me to hear, I think it was constructive for me to be aware of. We do beat our chest a lot on that, and maybe we should evaluate if we are overdoing it in some instances. I brought history up in this particular discussion for a specific reason. To make a case that CRNAs have never been required to be supervised by anesthesiologists. So I thought it was useful to trace the development of how CRNAs and anesthesiologists first came to work together.

    About liability, thank goodness Gasspassah posted a list of relevant court cases, so I didn't have to look them all up! To summarize, what the courts have determined is that liability for anesthesia rests with the anesthesia professional. The standard of care for anesthesia is the same regardless of the professional's licensure. So if there is anesthesia negligence, it is the CRNAs fault, not the surgeon. There is no such thing as "well, if this had been an anesthesiologist, it would be professional negligence, but since it is a CRNA, there is a different standard, and we cannot hold the CRNA responsible."

    About safety, we all agree anesthesia is safer now than it used to be. Is it because of better drugs, better monitors, more anesthesiologist involvement, or some other unidentified factor? I agree with you, I don't think we can prove anything one way or the other.

    About money, I would never imply in any way that you were motivated by money. But I think there was a particular time in the history of anesthesiology where greed got entirely out of hand, and that was what I was describing.

    It may seem like we have gotten far off the original post, but what we are talking about is the function of the ACT, and that was at the heart of the original question. I am going to lay my cards on the table. I enjoy lofty discussions, but it is probably no surprise to anyone here that I have an agenda. My hope is to positively (in my view) influence the opinions of young professionals. Future CRNAs, and since you are here, future anesthesiologists. I think anesthesia in the country is in a heck of a mess. It needs fixed. You young people are our hope. You have to figure out a way to make things better.

    Here is what I believe, and what I hope you will come to believe, or at least put in the back of your mind, and ponder on as you collect your own evidence through your professional evolution.

    At one time anesthesiology was a noble profession. Those first anesthesiologists treated CRNAs with respect, and the work was amicable. Then money and greed got in the way. Far too many anesthesiologist got drunk on all the money to be made, and these miserable, greedy so-and-sos ruined anesthesiology. It is this greedy legacy that now has hold of ASA leadership, making decisions based purely on economics. They insist that an anesthesiologist be involved in every anesthetic. Completely unnecessary. They say regional anesthesia should only be done by physicians. Ridiculous. You guys need to vote these bums out. They are not leading anesthesiology down the right path. Get rid of them, and return anesthesiology to its noble roots.

    You mentioned the term perioperative medicine awhile back. I really like that description. I might picture it differently than you do. Here is my idea of ACT functioning. CRNAs doing all the cases, under full scope of practice. That means they do the preop, do their own inductions, place their own blocks and lines, etc. Anesthesiologists are available for those times when a patient problem needs diagnosed and treated. Does every patient have need for (my view of) "perioperative medicine"? No, many cases could be done without the anesthesiologist ever interacting in any way. Are there cases done when patients have problems, and could benefit from the expertise of an anesthesiologist? Absolutely. Let the CRNAs do the cases, and get the ologist if there is a need. This is a way to make the best use of every team members talents and improve efficiency. It would probably solve the provider shortage.

    And the amazing reality is that some ACT indeed function in this way. I have only witnessed it myself a time or two. But I hear repeatedly from CRNAs at meetings, on these forums, etc about how their teams function fine, and what is all the fuss about at the national level. Well, if these CRNA-friendly anesthesiologists would get involved in their professional organization, maybe its policies wouldn't be so out of line with reality.
    I say it again, to you, and to anyone listening-VOTE THE BUMS OUT. Reclaim anesthesiology.

    Ok, I guess I better get the flamesuit out. Others have taken heat, it is probably my turn. But if there is even one person out there listening, who might look back on this some day and say "You know, that crazy CRNA might have been on to something there", then it will have been worth it.

    loisane crna
  5. by   alansmith52
    what is going on in our forum???
    really I've seen more just outright fights in the last several months than ever before. It seems they all fall under the guise of "open minded", "educational" gibrish.
    I am quite certain that AA's and MDA's have a forum where they can go to and complain about how much they hate us. If they think we are Haughty, concieded, self serving, INGNORANT why do they come here to talk to us.
    I don't see this battle changing. I don't really see a treaty on the horizon. Education and Eloquence has only made it easier for us to hurt each other with our communtication styles.
    normally I like a good fight but this is getting silly. I personally wouldn't mind if we could ban all non-CRNA's. before the polution is overwelming. first there was one AA now two and a couple doc's. I am just exasperated by this whole issue.
  6. by   Lorus
    Quote from alansmith52
    what is going on in our forum???
    really I've seen more just outright fights in the last several months than ever before. It seems they all fall under the guise of "open minded", "educational" gibrish.
    I am quite certain that AA's and MDA's have a forum where they can go to and complain about how much they hate us. If they think we are Haughty, concieded, self serving, INGNORANT why do they come here to talk to us.
    I don't see this battle changing. I don't really see a treaty on the horizon. Education and Eloquence has only made it easier for us to hurt each other with our communtication styles.
    normally I like a good fight but this is getting silly. I personally wouldn't mind if we could ban all non-CRNA's. before the polution is overwelming. first there was one AA now two and a couple doc's. I am just exasperated by this whole issue.
    It seems like you are upset with some of the negativity that surfaces on this board from time to time. I can understand that, but its counterproductive to perpetuate that negativity. It is important to have other anesthesia care providers participating on this board. The MD's and AA's on this board have valuable input and experience and should be welcome here.
  7. by   deepz
    Quote from loisane
    .....Let the CRNAs do the cases, and get the ologist if there is a need. This is a way to make the best use of every team members talents and improve efficiency. It would probably solve the provider shortage.....
    Exactly. I've often heard it said that there really is no provider shortage in American anesthesia. Only a maldistribution of providers.

    On the one hand, some folks say, get the docs away from CNBC, off the stock broker hotline, out of the lounge, into the ORs, and onto their own damn stools, doing cases. Not pretending to stupervise. Plenty of providers.

    But of course, for the average consumer to pay doctor-level prices for routine everyday bread and butter anesthesia, that's wasteful. And many MDAs would be bored to tears. Reading golf magazines, leaving the OR, on the phone to the broker anyway, etc.

    In the arcane terminology of third party reimbursement, 'non-medically directed' anesthesia departments such as Loisane describes above are the truly cost effective approach for hospitals. Many entrepreneurial MDAs understand this; they just won't turn loose of their control, as that would clearly show that 'supervision' is in fact nothing more than reimbursement lingo, and that arcane lingo is not now -- nor was it ever intended to be -- proscriptive of any standard of care.

    Listen to Loisane, kiddos; she knows her stuff.

    deepz
  8. by   TejasDoc
    Gaspassah,

    I haven't had a chance to say, but I REALLY appreciate the court cases you posted. I wish I could say that I've had time to look them up, I haven't. I've just been too busy with work stuff recently. I will take a look at some point, just don't know when yet. But thank you for posting those.

    Loisane ... you're right, this discussion has gotten pretty far away from the anesthesia care team topic that it started on. In the very end, I don't know what's going to happen with this model of care. If nothing else, I hope it ends up that CNRAs and anesthesiologists have an amicable relationship. From what I hear, in the private world, this is true.

    I think anesthesiology, from a physician point of view, is going to stress this perioperative role more and more. Right now, the ABA is considering tacking on more time in the ICU during an anesthesiologist's residency. Abroad, many anesthesiologists have to spend a year in ICU training as a part of their residency. A lot of physicians are changing their practices, cardiothoracic surgeons have to contend with interventional cardiologists, general surgeons with GI docs, neurosurgeons with interventional neuroradiologists ... everyone's practice will change eventually.

    I don't really know what's going to happen in our case. I disagree with Deepz, this is not an issue of economics. I don't imagine it is going to cost the health care consumer any less to get anesthesia from a CRNA than it would have from an anesthesiologist. As far as I know now, reimbursements are the same whether or not an anesthesiologist or a CRNA does the case, but in general, in the case of supervision or direction, the anesthesiologist takes half. So perhaps in that case, many of you are thinking that the reimbursement will simply drop to half, therefore the health care consumer is only paying half what they were before, to get anesthesia care (in this case, imagine there is no supervision, CRNAs are treated as exact equals to an anesthesiologist). So in this case, if an anesthesiologist does a case, he gets X amount, if a CRNA does a case, they get X amount.

    While I think this sounds like it would be agreeable to CRNAs, you know it would not be. Can you imagine the **** storm that the AANA would create if before, you got paid X to do an anesthetic, but now that nurses and physicians are equal in this matter, you got paid half of X? I just don't see that happening, so I don't think it's an issue of the economics of it all.

    You said you thought there might be cases when the expertise of an anesthesiologist would be needed, but not every case. But which cases? I imagine you wouldn't necessarily know, so that would mean that every hospital in America that performs surgeries should at least have a consultant anesthesiologist on staff, just in case one of those emergencies arises. But every hospital does not have an anesthesiologist, and they'll never get one if the anesthesiologist receives his/her only compensation from consultation.

    As for the leadership of the ASA. I don't really know. I know very little about the attitude of the leadership. From a financial point of view, I'll lead a very good life if supervision of CRNAs in an anesthesia care team stays the predominant model. And I know I'll lead a good life if anesthesiologists are the sole providers of anesthesia care in this country. But if CRNAs are doing all their own cases under a full scope of practice, well, how will this help me? You really just then become my direct competition for employment. The ASA is protecting the practice of anesthesiology for me ... so I wouldn't be reclaiming anesthesiology, I'd just be giving a bigger chunk to you if I tried to vote in a more pro-CRNA leadership. Why would I want to do that?

    Quote from deepz
    Exactly. I've often heard it said that there really is no provider shortage in American anesthesia. Only a maldistribution of providers.

    On the one hand, some folks say, get the docs away from CNBC, off the stock broker hotline, out of the lounge, into the ORs, and onto their own damn stools, doing cases. Not pretending to stupervise. Plenty of providers.

    But of course, for the average consumer to pay doctor-level prices for routine everyday bread and butter anesthesia, that's wasteful. And many MDAs would be bored to tears. Reading golf magazines, leaving the OR, on the phone to the broker anyway, etc.

    In the arcane terminology of third party reimbursement, 'non-medically directed' anesthesia departments such as Loisane describes above are the truly cost effective approach for hospitals. Many entrepreneurial MDAs understand this; they just won't turn loose of their control, as that would clearly show that 'supervision' is in fact nothing more than reimbursement lingo, and that arcane lingo is not now -- nor was it ever intended to be -- proscriptive of any standard of care.

    Listen to Loisane, kiddos; she knows her stuff.

    deepz
    Deepz, I'm not sure you've ever had anything positive or constructive to say in this discussion, if I'm mistaken, I'd hope someone would point it out to me. It's always something negative, it's always a jab at anesthesiologists, the ASA, or AAs, and rarely is it backed up by any kind of real facts or substantial proof. This last message is a great example, you could have made a simple comment about the anesthesia provider shortage and supervision not really being "proscriptive of any standard of care", but you ruined a perfectly reasonable argument with comments about CNBC, golf, and stock brokers.

    Again though, I'm going to agree with you, Loisane makes good posts, people could learn a lot from her approach, including me.

    TD
  9. by   WntrMute2
    Quote from TejasDoc
    Gaspassah,

    I haven't had a chance to say, but I REALLY appreciate the court cases you posted. I wish I could say that I've had time to look them up, I haven't. I've just been too busy with work stuff recently. I will take a look at some point, just don't know when yet. But thank you for posting those.

    Loisane ... you're right, this discussion has gotten pretty far away from the anesthesia care team topic that it started on. In the very end, I don't know what's going to happen with this model of care. If nothing else, I hope it ends up that CNRAs and anesthesiologists have an amicable relationship. From what I hear, in the private world, this is true.

    I think anesthesiology, from a physician point of view, is going to stress this perioperative role more and more. Right now, the ABA is considering tacking on more time in the ICU during an anesthesiologist's residency. Abroad, many anesthesiologists have to spend a year in ICU training as a part of their residency. A lot of physicians are changing their practices, cardiothoracic surgeons have to contend with interventional cardiologists, general surgeons with GI docs, neurosurgeons with interventional neuroradiologists ... everyone's practice will change eventually.

    I don't really know what's going to happen in our case. I disagree with Deepz, this is not an issue of economics. I don't imagine it is going to cost the health care consumer any less to get anesthesia from a CRNA than it would have from an anesthesiologist. As far as I know now, reimbursements are the same whether or not an anesthesiologist or a CRNA does the case, but in general, in the case of supervision or direction, the anesthesiologist takes half. So perhaps in that case, many of you are thinking that the reimbursement will simply drop to half, therefore the health care consumer is only paying half what they were before, to get anesthesia care (in this case, imagine there is no supervision, CRNAs are treated as exact equals to an anesthesiologist). So in this case, if an anesthesiologist does a case, he gets X amount, if a CRNA does a case, they get X amount.

    While I think this sounds like it would be agreeable to CRNAs, you know it would not be. Can you imagine the **** storm that the AANA would create if before, you got paid X to do an anesthetic, but now that nurses and physicians are equal in this matter, you got paid half of X? I just don't see that happening, so I don't think it's an issue of the economics of it all.

    You said you thought there might be cases when the expertise of an anesthesiologist would be needed, but not every case. But which cases? I imagine you wouldn't necessarily know, so that would mean that every hospital in America that performs surgeries should at least have a consultant anesthesiologist on staff, just in case one of those emergencies arises. But every hospital does not have an anesthesiologist, and they'll never get one if the anesthesiologist receives his/her only compensation from consultation.

    As for the leadership of the ASA. I don't really know. I know very little about the attitude of the leadership. From a financial point of view, I'll lead a very good life if supervision of CRNAs in an anesthesia care team stays the predominant model. And I know I'll lead a good life if anesthesiologists are the sole providers of anesthesia care in this country. But if CRNAs are doing all their own cases under a full scope of practice, well, how will this help me? You really just then become my direct competition for employment. The ASA is protecting the practice of anesthesiology for me ... so I wouldn't be reclaiming anesthesiology, I'd just be giving a bigger chunk to you if I tried to vote in a more pro-CRNA leadership. Why would I want to do that?



    Deepz, I'm not sure you've ever had anything positive or constructive to say in this discussion, if I'm mistaken, I'd hope someone would point it out to me. It's always something negative, it's always a jab at anesthesiologists, the ASA, or AAs, and rarely is it backed up by any kind of real facts or substantial proof. This last message is a great example, you could have made a simple comment about the anesthesia provider shortage and supervision not really being "proscriptive of any standard of care", but you ruined a perfectly reasonable argument with comments about CNBC, golf, and stock brokers.

    Again though, I'm going to agree with you, Loisane makes good posts, people could learn a lot from her approach, including me.

    TD
    As a CRNA I too am getting tired of the tone of the posts in general. This board is sounding more and more like the studentdoc fourm some love to bash. There are good and bad providers in all aspects of healthcare and the sooner we work to eliminate those and not compete to provide healthcare the better. The Docs that have been here have all been helpful and controversial at the same time. We have managed to drive some of them away as well as some of the experts in our field. I too am not finding much of anything of interest here any longer. I check back from time to time but in general, so long guys and good luck.
  10. by   deepz
    Quote from TejasDoc
    .....I disagree with Deepz, this is not an issue of economics. I don't imagine it is going to cost the health care consumer any less to get anesthesia from a CRNA than it would have from an anesthesiologist. As far as I know now, reimbursements are the same whether or not an anesthesiologist or a CRNA does the case, but in general, in the case of supervision or direction, the anesthesiologist takes half. ....
    Well, what can one say about such ignorant speculation? The 50/50 conditions you cite, TD, apply only to Medicare reimbursement. (And you furnish no references!) It appears you might possibly need a bit more experience out in the real world of anesthesia and anesthesia billing before you pontificate about what is cost-effective. You just don't know what you don't know. Sorry.


    [/QUOTE]Deepz, I'm not sure you've ever had anything positive or constructive to say in this discussion, if I'm mistaken, I'd hope someone would point it out to me. It's always something negative, it's always a jab at anesthesiologists, the ASA, or AAs, and rarely is it backed up by any kind of real facts or substantial proof. This last message is a great example, you could have made a simple comment about the anesthesia provider shortage and supervision not really being "proscriptive of any standard of care", but you ruined a perfectly reasonable argument with comments about CNBC, golf, and stock brokers.[/QUOTE]

    Touchy, touchy. What's your HANDICAP? Negativity and snottiness, again, seem to be *your* specialty, doctor. "Point it out" to you? Again, we nurses don't need to *prove* anything to you. Again, we don't need your supervision in order to form and express freely our own opinions. You, sir, are perfectly welcome to delete my every post. You are also welcome to your own opinions (however speculative and uninformed, and I'm sure there might be more appropriate places for you to post them than here) and yet we here are under no obligation to take your posts as anything more than the egoistic voice of inexperience. Again, you post ad hominem attacks. Again, that M-Diety attitude shining through. Enough already.

    !
  11. by   gaspassah
    As far as I know now, reimbursements are the same whether or not an anesthesiologist or a CRNA does the case, but in general, in the case of supervision or direction, the anesthesiologist takes half.
    i'm not real sure but i think i read it on here once and i looked it up in the medicare website, but i think a crna working independantly can bill and is reimbursed 75% of mda billing. i'm not real sure about this one tho.
    d
  12. by   alansmith52
    TD
    I have much the same resent (if that's what you call it) as deepz.(although he is older and wiser) I appreciate that for some fraction of your posts you've had a calm tone. I just wanted you to know that I noticed that.
    I want to explain what you call this (golf.. bla bla bla paradigm) from what I saw when I was working in the ICU and the floor.
    Your right that they may not be golfing or checking their stocks but from a nurses standpoint they are ABSENT. As we stand there at the bedside doing the labor of healing, Where are they??? I used to ask myself that every day. He came in and wrote orders. Where is he going now? Oh, he must have other patients to round. on but everyday. He can never stay and help take care of HIS patients? Ever. I never saw a physician paying the price I thought I or any of my colleges were paying physically. So in one light I agree they may not be golfing but one thing is true. They aren't here at the bedside either. They must be somewhere.... Doing something... and one is left up to his own imagination to speculate where and what exactly they are doing day in and day out whilst their patients sit in a hospital room. I want to see em swing a hammer, pick up a rifle and get muddy if you will. I do think they could earn mine and many others respect.
  13. by   Passin' Gas
    Quote from alansmith52
    TD
    Your right that they may not be golfing or checking their stocks but from a nurses standpoint they are ABSENT. As we stand there at the bedside doing the labor of healing, Where are they??? I used to ask myself that every day. He came in and wrote orders. Where is he going now? Oh, he must have other patients to round. on but everyday. He can never stay and help take care of HIS patients? Ever. I never saw a physician paying the price I thought I or any of my colleges were paying physically. So in one light I agree they may not be golfing but one thing is true. They aren't here at the bedside either. They must be somewhere.... Doing something... and one is left up to his own imagination to speculate where and what exactly they are doing day in and day out whilst their patients sit in a hospital room. I want to see em swing a hammer, pick up a rifle and get muddy if you will. I do think they could earn mine and many others respect.
    At the risk of destroying a cliche....you can't know another one's life until you've walked in his/her moccasins....or something like that. And in the novel tradition of LONG posts:

    The art of nursing derives from our continual contact with the patient over time...hours....sometimes days and even weeks for some patients. We continuously monitor, watch for trends, coordinate therapies....etc. The patient(s) we have are our sole responsiblility for a time limited period, an 8, 10, 12h shift. For anesthesia...we have the luxury of one patient at a time from preop to intraop to postop....that's our one and only responsibility.

    For docs...well, depending on the practice...rounds in the morning, often starting at 0600. An internal medicine doc friend said he averages 10-15 inpatients, sometimes up to 30 during a really bad flu season or covering his partner's patients on a weekend. Hmmm, 10 min/patient X 15 patients = 150 min. That's 2 1/2h alone for MINIMAL assessment of what's going on with a patient. OK, so that's morning rounds...0600-0830. Office hours from 0900-1700. Since it's difficult to fully assess a patient in 10-15 min, the day will probably run over. Most practices shoot for seeing 25-30 patients a day. Not a lot of 'get to really know you' time. The exceptional practitioners are able to do it. Often spending extra time when warranted...ooops, there goes the schedule. Then there's a pile of phone calls from patients, other physicians, nurses, parents, friends at the 'end' of the day. Oh, then there's the return to the hospital (or more facilities depending on where the patients are admitted) to revisit the 'critical' patients. That's probably another hour, at least.

    My point is there's a lot we, as nurses, may not appreciate what goes on in other professions. I am acutely aware of physicians who hit the golf course at 1000 after rounds and breakfast. I'm not that naive. What I wanted to point out was one of, what I view, as a basic difference between medicine and nursing....a diagnosis/pill/treatment and a presence/continual monitoring/always there. That's a broad generalization. The two disciplines cross over in many facets. When it's needed, the doc is there at the bedside for an hour (I hear cyberspace gasps!), but yes, in the ICU environment there's been many times the docs....attendings, fellows, residents, interns, and private practice doctors, have spent long periods of time talking with the patient and family, assessing the overall situation and evaluating what will be the best course for this patient at this time.

    We, as nurses, are assigned 2 patients in ICU, one intubated, 5 IV infusions, comatose, grieving family; second patient, 2 days postop CABG, IABP dc'd that am, sitting up in chair late evening, eating dinner. Really, who are you going to spend more of your time with? And are you going to be called at 0930 after 12h nights to come in and d/c the nipride infusion on the postop carotid? When your shift is done, it's done. This is not including the nit-noid nursing meetings or ACLS or (gasp) narcotics count is off. When you're done with the shift you go home and are not contacted about a patient until you show up for the next shift.

    Not to discount the misbehavior described. I've seen that in action. Yoda the cardiologist (Star Wars to those too young to know who Yoda is; he only looked like him, not near as calming and pleasant of a personality) would throw a HISSY FIT if the charts were not lined up, in order, at 0700 SHARP PRIOR to his arrival in the CICU. Woe be to the newbie who failed to have the chart up there on time....That behavior was uncalled for, and as I grew as an RN in experience, my responses to those individuals was adapted to "the progress notes are in the second drawer under 'progress notes'", and under my breath, same damn place they've been since 1982.


    And before deepz kicks in: this is a post attempting to open minds in the ICU environment.

    For the anesthesia environments I've been exposed to, yes, we had several donut-eating, stock broker watching dead weights who didn't carry their fair share. Group of 8 docs and about 24 CRNAs. Complaints from CRNAs, surgeons, et al, the donut eaters were drummed out of the group. Down to 6 docs, and yes, they are working, involved in the cases, and OMG actually MEETING the 7 TEFRA rules and DOCUMENTING if the 7 TEFRA rules were NOT met! What has this world come to?!! (there's no tongue-in-cheek smilie, we need one)

    PG

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