Should Anesthesia Be an only MD Profession - page 4

I knew this would get your attention. This question is for those seeking, in current studies, and practicing anesthesia. I understand the economics and statistics for various practice... Read More

  1. by   Kason
    School is what you make out of it! I agree with oldsalt, I feel that what you put in to it, is what you get out of it. As for MDAs visiting this chat site, I appreciate the MDAs (like Tenesma) that take the time to answer clinical questions.
  2. by   gaspassah
    i agree with benna's dad on a couple of issues. at kaiser we get alot of training in regional, some invasive lines etc. however when you graduate many jobs are mda run. and they believe that invasive lines and regional are practicing medicine, and therefore restrict the crna practice. this in turn makes the crna less marketable if he/she chooses to move on, or less confident in doing those procedures if they go independant, having not done them for some time.
    at kaiser we also get alot of fiberoptic lab, but again depending on where your clinical is the mda's determine who does the fiberoptic intubations and they are usually a little stingy in letting students do them.
  3. by   Pete495
    I have a question for all you old gas passahs(CRNA's). Did you have the chance to learn clinical procedures while in CRNA school, or were they not taught?

    Many have the perception that in the past clinical procedures were only taught to MDA's rather than CRNA's, and now that there is a shortage of anesthesia care providers, CRNA's are doing more today than they ever have in the past. Please remember this is a general perception, not MY perception. (I don't want ragged on for this).

    The scope of practice for CRNA's has definitely expanded, as one should expect. Has the scope of practice for MDA's expanded as well? I am hesitant, but would have to say yes. In the face of increasing health care demands such as insurance, reimbursement, and delegation, the role of the MDA has also expanded. It is a political nightmare for both MDA's and CRNA's. One could argue that CRNA's are becoming more clinical, and MDA's are becoming more of an authoritative figure, but I do not believe this to be the case. I believe they should and do work together although the scopes of practice might be different. I also firmly believe that we can both learn from each other.

    On another front, I don't understand why schools limit the CRNA's scope of practice, including the insertion of interscalene blocks or invasive lines. It makes me wonder if they are worried about CRNA's performing difficult procedures. On the other hand, if these CRNA's don't want to perform these techniques, then they should not be doing them. One can only do what he is comfortable with. Is it OK to be a CRNA and not do these procedures? I think every CRNA should have the ability to cover his scope of practice. It is not acceptable to pass it off to someone else, but it is acceptable to pass of someting one is not trained or comfortable doing. That is why I pose the question to old gas passahs. Because I know there are a lot of CRNA's who do not care or do not want to learn these procedures. And a lot of the older fellas are simply content with their current job situations. I know this from talking with and meeting many CRNA's.

    Enough rambling for now.
  4. by   WntrMute2
    [QUOTE=Pete495]I
    On another front, I don't understand why schools limit the CRNA's scope of practice, including the insertion of interscalene blocks or invasive lines. It makes me wonder if they are worried about CRNA's performing difficult procedures. On the other hand, if these CRNA's don't want to perform these techniques, then they should not be doing them. One can only do what he is comfortable with. Is it OK to be a CRNA and not do these procedures? I think every CRNA should have the ability to cover his scope of practice. It is not acceptable to pass it off to someone else, but it is acceptable to pass of someting one is not trained or comfortable doing. That is why I pose the question to old gas passahs. Because I know there are a lot of CRNA's who do not care or do not want to learn these procedures. And a lot of the older fellas are simply content with their current job situations. I know this from talking with and meeting many CRNA's.QUOTE]

    Remember folks that most (not all certainly) ORs are medically directed. So while schools don't limit these experiences, the MDA might and there is little anyone con do about it especially at the moment when the MD picks up the needle for that central line insertion. There may be many days that this happens and unfortunatly your CRNA will give you the old shoulder shrug and the look that says "don't fight it". They have to work daily with these MDAs and don't want their own lives made miserable. I think these individuals need to find the courage to be better student activists but remember if the hospital wants medical direction, the MD is able to control what you will and won't do. Just observe who wins when there is a disagreement about how to do a case between the CRNA and the MDA. Rarely will the MD give in, the CRNA does. I know this isn't true in those practice settings where there is no medical direction but if there is medical direction the battle for control has been given away.
  5. by   Oldsalt
    Very recently I was involved in a recent case (craniotomy - during a locums assignment) in which a central line was required.

    After induction, the MDA strolled in and started looking for the Central line kit. I indicated that I could place it, if by doing so, it didnt "causes any issues."

    He blinked at me and asked me directly how, where, and why it was indicated.

    I listed out an exact description on indications, landmarks, placement considerations, and contraindicatations (quickly w/o hesitancy) and experience. He said ok and left.

    Afterward, I was told by the staff that I was the first CRNA every to do that in that institution. Ever. Furthermore, that specific MDA did not like anesthetist to do anything (so kudos for him for stepping out).

    Take away point: if you want to do something just ASK- the results can be surprising- Additionally....be knowledgeable...be prepared...Be inquizzative... Be respectful ...and continue to ASK, ASK, and Finally ASK again....


    Regards
  6. by   WntrMute2
    Quote from Oldsalt
    Very recently I was involved in a recent case (craniotomy - during a locums assignment) in which a central line was required.

    After induction, the MDA strolled in and started looking for the Central line kit. I indicated that I could place it, if by doing so, it didnt "causes any issues."

    He blinked at me and asked me directly how, where, and why it was indicated.

    I listed out an exact description on indications, landmarks, placement considerations, and contraindicatations (quickly w/o hesitancy) and experience. He said ok and left.

    Afterward, I was told by the staff that I was the first CRNA every to do that in that institution. Ever. Furthermore, that specific MDA did not like anesthetist to do anything (so kudos for him for stepping out).

    Take away point: if you want to do something just ASK- the results can be surprising- Additionally....be knowledgeable...be prepared...Be inquizzative... Be respectful ...and continue to ASK, ASK, and Finally ASK again....


    Regards
    I couldn't agree with Oldsalt's post more. During my training I placed many more lines, did many more blocks than most of my classmates because (I believe) I showed interest in learning. I ssearched for reasons to discuss the case, indications and other stuff with the MDA before, during and after the case. Many times the MDA said "sure, get your gloves on." Sometimes, they wouldn't even glove up themselves. Talking about the reasons for success or failure as well as showing interest in what they are trying to teach went a long way. A lttle sucking up also went a long way and I really did appreciate the teaching they did. I'm afraid that I did find CRNAs generally lacking in teaching central line insertion, sure they could do it but the MDAs (in this instance) seemed better teachers.
  7. by   loisane
    There are so many points I want to respond to, please forgive me if I can't remember which individual brought them up.

    I believe one can make a case that anesthesia is more nursing than medicine. Medicine is curative, nursing is supportive. Anesthesia doesn't cure anything. Our job is to support the body, while the surgeon works the medical side of the case.

    It is important to remember that the term doctor does refer to education. We have lots of doctors in nursing. The correct term for a medical person is physician. We can help the public understand this distinction by being meticulously careful with our language. (A real challenge, I find myself slipping all the time)

    To the poster who said CRNAs are doing more than they used to because of the shortage, I disagree. Oldsalt points it out well. CRNAs used to do it all. Why now do we have a generation of CRNAs who are limited in their scope of practice? It is an important question.

    Those of you who said expressing interest is important, I agree. If SRNAs or CRNAs want to be "lazy" they can easily get away with it. You can't sit back and wait for someone to hand it to you.

    On the other hand, there are situations where the most determined SRNA or CRNA will face obstacles in their effort to practice with a full scope. The phrase "follow the money" comes to mind. The procedures at issue are revenue generating. Whoever does the block, inserts the line, or does the fiberoptic is the one who gets to bill for it, and get paid for it. This is the source of conflict in many anesthesia departments.

    Great comments about important issues. What is the solution? I haven't a clue. I do know that to maintain accreditation, nurse anesthesia programs are being mandated to offer more of these type of experiences. That should help.

    And our national association has made a committment to support CRNAs in independent practice. Why is that so important, when the greatest majority of CRNAs work in a team setting? Because independent CRNAs (by definition) are working at a full scope of practice. Supporting them protects all of our rights, so that ACT CRNAs can work at a full scope also, if these other issues can be successfully addressed.

    loisane crna
  8. by   Oldsalt
    Wondeful comment Loisane ...Curative vs Supportive - Havent thought about it in that light - nice insight.

    An earlier post also had indicated that Anesthetist Schools are be required to offer a broader experience for students. That must be new for the new graduates I have met have not had such training.

    Does anyone know specifically how that is being done and enforced?

    And what type of experiences are being mandated?

    Regards...
  9. by   deepz
    Quote from Oldsalt
    ...Curative vs Supportive - Havent thought about it in that light ...

    http://www.gaspasser.com/unique.html

    deepz
  10. by   Pete495
    good LINK DeepZ. I'd been looking for something that described the nursing side of anesthesia because all i've heard lately from peers is that anesthesia is not nursing, it's medicine. It's difficult to describe the support that a registered nurse anethetist provides during the course of anesthesia. Granted, a lot of it is physiological, but it also has a lot to do with reading your patient, their vital signs, and even their appearance and reaction to anesthesia and your procedure. I also think it is ironic that most CRNA's through a discussion on allnurses said they would never go back to bedside nursing. I cannot blame them at all. I just found it kind of funny.

    Also, I believe I said that there was a PERCEPTION that CRNA's are doing more because of the shortage. I think I also pointed out that I would probably get ragged on for that comment. Not that it matters. I posed it as a question anyway. I wanted to know if anesthetists were doing more, less, or about the same when it comes to pushing drugs and doing procedures. So far the general response I've gotten is that CRNA's are doing what they want and are able to do. Should a CRNA have to ask the MDA to put in a central line ? Ha! See, the line between physician supervision and independent practice is still murky even in the face of independent practice.
  11. by   loisane
    Curative vs. supportive. Yep, sometimes those nursing theory classes do have some substantive meaning! (hehe) Seriously, I believe these questions are important. We're all clinicians, we want to cut to the chase and talk about how to do things, based on outcomes, something applicable, etc. So, sometimes we are impatient with less concrete issues. But there is also a place for philosophy, theory and more abstract discussions, such as these.

    In regard to what clinical experiences SRNAs need to graduate, there are new standards effective this year. There are increases in total number of cases, and in most categories. The AANA website has the new standards, under the accreditation section. It is members only, so you need your membership and PIN to get access.

    loisane crna
  12. by   loisane
    David said
    "Many have the perception that in the past clinical procedures were only taught to MDA's rather than CRNA's, and now that there is a shortage of anesthesia care providers, CRNA's are doing more today than they ever have in the past. Please remember this is a general perception, not MY perception. (I don't want ragged on for this).
    The scope of practice for CRNA's has definitely expanded, as one should expect."

    I hope I don't sound like I am ragging on you. Instead, I am making the point that I believe people with this perception are wrong. Those with this perception are probably the same people who think CRNAs are RNs who have had a little extra on the job training, and are just there to help the MDA. In other words, they have bought the ASA rhetoric that anesthesia is better when MDs are involved, and the ideal situation is to have 100% MD delivered anesthesia.

    This is not how anesthesia has been delivered historically. CRNAs have ALWAYS been involved in full scope of practice anesthesia. It is not something new, no matter what you have heard. I work with CRNAs who practiced anesthesia when there were NO MDAs around. Of course they did it all, there wasn't anybody else! MDAs might have existed elsewhere at that time, but not in this town.

    I believe that the idea that "CRNA's are doing more today than they ever have in the past" is a myth. Nothing personal, just MHO.

    loisane crna
  13. by   smiling_ru
    I was fortunate in that the school I attended allowed us to do all procedures and a lot of them.

    When I started working I was told that there were certain procedures which were only performed by the docs. Central lines, some blocks. I approached each MDA and stated that these were skills I had learned in school and that I did not want to lose. They agreed that I should not lose those skills, and I place my own lines/blocks. But, I think I am the only CRNA where I work who is placing central lines. The only reason I can think of for this, is that the others have not made a point of doing them.

    The supervision model is in use, so the MDA's do come in on induction. But, they do not push my drugs, they hold the mask or hand me the OETT, no infringement on practice, but an extra set of hands if needed.

    I know that there are plenty of places where it is a power issue and nothing will change the status quo. But, you never know until you ask.

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