Jane Fitch MD, prior CRNA, now Anesthesiologist elected president ASA - page 13

Game over people... ASA president... Jane Fitch. Thoughts?... Read More

  1. 1
    Quote from subee
    I do not deny the need for anesthesiologists. However, just believe that we need far less of them. After 30 years of experience, I don't see any difference in outcomes and the MDA's are too educated for the cases they do. However, there is that subset of cases that require a host of medical decisions that require MD attention. For the other 90% of cases, I don't need them for decisions, I need a set of educated hands for difficult intubation, etc.
    I don't think there are any anesthesia cases that need a physician-anesthesiologist. Anesthesiologists that are fellowship trained can bring a lot of speciality knowledge by that experience to anesthesia, but I don't think that is not something that could not be overcome by similar fellowship training or experience by CRNAs.
    Sating that 10% of anesthesia cases need a anesthesiologist is anecdotal at best, and really doesn't make sense when you look at the research or all the CRNA only hospitals with equivalent safety records as mixed models of anesthesia provider hospitals or anesthesiologist only hospitals.
    NRSKarenRN likes this.

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  2. 0
    Actually, this is not anecdotal. About 10 years ago there was a study published in the AANA Journal that consisted of giving questionnaires to the CRNA's and MDA's working at Kaiser hospitals in California. The question was how many cases required the presence of MDA and both sides agreed on the 10% figure independently of each other. I remember thinking that was exactly the number I would have picked. However, I respectfully disagree with you. I am happy not doing liver transplants in adults or children, cranio-facial procedures in children, fetal procedures and do not think that CRNA's should be doing these cases except as the second anesthesia provider on these cases, which are often given 2 providers. I don't want to do anything with preemies and think it's hubris to believe that you are qualified to do the above cases. The other 90%? Sign me up.
  3. 0
    Quote from subee
    Actually, this is not anecdotal. About 10 years ago there was a study published in the AANA Journal that consisted of giving questionnaires to the CRNA's and MDA's working at Kaiser hospitals in California. The question was how many cases required the presence of MDA and both sides agreed on the 10% figure independently of each other. I remember thinking that was exactly the number I would have picked. However, I respectfully disagree with you. I am happy not doing liver transplants in adults or children, cranio-facial procedures in children, fetal procedures and do not think that CRNA's should be doing these cases except as the second anesthesia provider on these cases, which are often given 2 providers. I don't want to do anything with preemies and think it's hubris to believe that you are qualified to do the above cases. The other 90%? Sign me up.
    Actually, what you just described is anecdotal evidence. It was based on provider opinions only. What I stated for my rationale was based on research studies looking at safety between independent CRNAs and medically supervised CRNAs.
    There isn't a type of anesthesia case that I know that a CRNA somewhere isn't doing or hasn't done.

    http://www.aana.com/newsandjournal/D..._0495_p117.pdf

    Are you referring to this study? This study was based on the opinions of CRNAs and MDAs from one ACT hospital. This study in no way can be utilized to determine the need for supervision, which other research studies have disproven, nor can it used to determine the general opinions by CRNAs or MDAs on the perceived need for CRNA supervision by MDAs outside of this one hospital.

    This doesn't even account for the fact that most ACT hospitals are actually unable to complete the TEFRA requirements for medical supervision beyond 1:1 to 1:2 ratio.
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    Well, unless someone else is following this thread, we may never know what cases CRNA's are not doing.
    Got me with that "study." However, merely pointing out that there is agreement among SOME CRNA's that some cases require constant MDA attention. If my kid was having a liver transplant, I'd expect to be in a medical center that provided a pediatric anesthesiologist. It's not just giving the anesthesthetic, it's the pre-op preparation and the post-up ICU care that's included in these complex cases. Cranio-facial surgery requires a team consisting of ocular surgeon, neuro-surgeon and plastics.
    Think it will be a cold day in hell before any parent goes out of his/her way to request a CRNA and I wouldn't trust any CRNA who thinks he/she is qualified to do this case. Like you will be released from doing cases to attend the pre-op planning meetings these cases require. Like you actually have required significant clinical experience on these cases. Puhleeze.
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    Quote from subee
    Well, unless someone else is following this thread, we may never know what cases CRNA's are not doing.
    Got me with that "study." However, merely pointing out that there is agreement among SOME CRNA's that some cases require constant MDA attention. If my kid was having a liver transplant, I'd expect to be in a medical center that provided a pediatric anesthesiologist. It's not just giving the anesthesthetic, it's the pre-op preparation and the post-up ICU care that's included in these complex cases. Cranio-facial surgery requires a team consisting of ocular surgeon, neuro-surgeon and plastics.
    Think it will be a cold day in hell before any parent goes out of his/her way to request a CRNA and I wouldn't trust any CRNA who thinks he/she is qualified to do this case. Like you will be released from doing cases to attend the pre-op planning meetings these cases require. Like you actually have required significant clinical experience on these cases. Puhleeze.
    There are surveys from the AANA that shows the types of cases that CRNAs do, but I would have to really search to find those.
    What you are still stating is an opinions and not facts. You assume that CRNAs are not qualified to do x, y, or z based on those opinions which are not supported by facts or any research studies.
    I would think from your statements that you spent the majority of CRNA career working in ACT/medically supervised environment. I have spent the majority of my time in a military setting working independently from day 1 so our opinions are probably going to differ on the need for medical supervision.
    The real difference is that I can state for a fact there are no research studies that show a difference in safety between independent CRNAs and medically supervised CRNAs.

    I would want the person with the most experience and has had the best outcomes doing my anesthesia or my family's anesthesia sometimes that will be a CRNA and sometimes that will be an MDA. I certainly don't want the MDA that never actually does their own cases going anywhere near me or my family.
    NRSKarenRN likes this.
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    [QUOTE=loveanesthesia;8246247]'Retrospective studies don't prove anything!'

    Well I wouldn't go that far-I think we have determined that cigarette smoking is hazardous based on retrospective data.

    --The truth is that retrospective studies don't prove causality. You need prospective, controlled, randomized trials to establish causal relationships--i.e., to definitively answer the hypothesis. Retrospective studies can identify correlations, but these correlations are not equivalent to causation. Here's an example to illustrate my point: Dr. Amazing Researcher decides to study 5,000,000 veterans who got their care at the Veterans Hospital of BFE in the last 10 years. His question: does Coca-cola consumption increase the risk of developing lung cancer? In his retrospective analysis of these patients he finds that 5,000,000 of these vets drink Coca-cola and, shockingly, all of the subjects developed lung cancer. Dr. Amazing Researcher (mistakingly) concludes that Coca-cola drinking causes lung cancer. There's one problem though, the researcher failed to look at smoking history in his analysis. In doing so, he overlooked the fact that all of the test subjects happen to smoke 5 packs of Marlboro reds a day. This phenomenon is known as a confounder, and it's a fundamental flaw in ANY retrospective study.

    Retrospective studies can identify correlations, but unfortunately correlation does NOT equal a causal relationship. In my dumb example above Dr. Amazing Researcher identified a correlation between Coca-Cola consumption and the development of lung cancer, but of course we know there is no causation between the two--the REAL cause of lung cancer in his study population was smoking like a chimney.
    jwk likes this.
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    Criteria for Causation There will never be a way to reasonably provide a high powered RCT trial for safety in anesthesia, but when you look at the Hill criteria for causation every step needed for causation according to these rules have been met by large retrospective studies on safety in anesthesia except for expermentation.
    Similarly, it wouldn't matter if the AANA did a large RCT if the results weren't to the liking of the ASA the ASA would then complain it was funded by AANA and for X reason it wasn't valid even if that reason had already been disproven. It is a consistent pattern that ASA never fails to not reproduce.
    The ASA sounds like a broken record when it comes to APNs. It is sad when you find court cases from the early 1900s where medical associations prior to the ASA are using the exact same arguments that they do today about CRNAs.
    Ether511 that whole example you gave wasn't about causation it was about bias/internal validity, which is harder to control without randomization.
    Last edit by wtbcrna on Dec 13
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    However, merely pointing out that there is agreement among SOME CRNA's that some cases require constant MDA attention. If my kid was having a liver transplant, I'd expect to be in a medical center that provided a pediatric anesthesiologist.
    I agree. All of the MD's at our hospitals are board certified with fellowship training in either hearts, peds, neuro, pain, regional, or even transplant anesthesia. There is no question that these men and women are extremely qualified and there is no equivalent CRNA schooling or training to obtain this type of education. Many say there are "experienced" CRNA's in these fields, but that is subjective, just as if a MD was doing the case. None of our CRNA's do these cases as only the fellowship trained MD's do them. The ACT cases may be kids or neuro, but they are not the severe cases.


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