What do you think (if anything) MDA's will do... - page 2
to protect their turf? If there's one thing I learned in my short thirty three years on this planet it is that interest groups always TEND to seek for ways to maximize THEIR interests (nothing wrong... Read More
Aug 29, '02What do MDA's learn in Medical School that CRNA's don't learn through the CRNA training?
What is differant about the 3 years of residency that an MDA goes through that the CRNA goes through? (not including length of time of both residencies I think the CNRA is shorter)
Is the experience during residency training for both MDA and CNRA different?
Are the drugs and the processes and procedures for administering the drugs differant between the 2:
a) before graduation (i.e. during school)?
b) after graduation (during residency as well as after)?
After both MDA's and CNRA's are out in the "field" practicing are there any differences (please provide a specific example, high level)?
When new drugs specific to Anesthesiology come on the market do CNRA's learn the new process and/or procedure on administering the new drug the same as an MDA would?
Is MDA and CNRA collaborative research currently going on that any of you know of (provide link)?
best regards to all,
Aug 30, '02> What do MDA's learn in Medical School that CRNA's don't learn > through the CRNA training?
in medical school:
year 1, the basics of medicine (anatomy, physiology, embryology, biochemistry, pharmacology)
year 2, more basics of medicine (pathology, more pharmacology, physical diagnosis)
year 3, clinical-based medicine (internal medicine, surgery, obstetrics-gynecology, psychiatry, family medicine and pediatrics)
year 4, more clinical-based medicine (critical care, neurology and further work in areas of interest - in my case, 5 months of surgery, 3 months of surgical critical care, 1 month neurology, etc..)
the bottom line is that medical school provides the foundation for understanding the management of the patient in various situations and settings
> What is different about the 3 years of residency that an MDA
> goes through that the CRNA goes through? (not including
> length of time of both residencies I think the CNRA is shorter)
> Is the experience during residency training for both MDA and
> CNRA different?
the three years of residency (that is if an MDA chooses not to do a fellowship in critical care, pain management, pediatric anesth, cardiac, thoracic, vascular, neuro, etc.) revolves pretty much around the OR. In my case, i average about 2 to 4 cases a day, and take call about 5 to 6 times per month (unfortunately for my receding hair line, not much sleep ), which translates into 85-95 cases a month *36 months = 3240 cases by the end of residency... we manage airways around the hospital, we run the SICU and provide ICU consults to other ICUs (pulmonary, medical, pediatric, neo-natal, etc.) in the hospital, we tend to manage the more complicated/difficult patients. Now that doesn't mean that some experienced CRNAs can't hold their ground with very comlicated patients, but the question was regarding the difference in training. oh, and i can't forget to mention having to "survive" internship, where we learn the basics of patient management on the floors.
> Are the drugs and the processes and procedures for
> administering the drugs different between the 2:
> a) before graduation (i.e. during school)?
> b) after graduation (during residency as well as after)?
I am sorry, I don't understand the question.
> When new drugs specific to Anesthesiology come on the
> market do CNRA's learn the new process and/or procedure on > administering the new drug the same as an MDA would?
when new drugs come to market both CRNAs and MDAs administer those drugs, there isn't any technical difference... the only difference may lie in clinical decision-making (ie: when to or not use a drug)
> Is MDA and CNRA collaborative research currently going on that > any of you know of (provide link)?
i am sure there is, but none that i can name
I hope I helped out in some way - bottom line, CRNAs and MDAs provide care for patients, and the main difference in training lays in the breadth of experience/knowledge....
Aug 30, '02to aspire to the same level of independence as MDA's. Having said that I do think it IS possible to achieve relative parity in education between CRNA's and MDA's with regard to physiology AND pathophysiology as it relates to anesthesia. That is because while the MD is responsible for all the information that a GP must acquire BEFORE he/she can focus upon anesthesia, the CRNA carries no such burden. In addition, consider that most pre-med students DO NOT take courses like Anatomy, and Physiology until medical school (because they are not required by most medical schools, indeed they are often discouraged). This is contrasted with BSN students who must have at least three semesters as part of their PREREQUISITES in many cases (in addition many students like myself take AN ADDITIONAL three or four semesters of advanced A&P courses as undergraduates). In addition, any concerns that you have about the paucity of education (compared to MDA's) that CRNA's possess COULD be addressed with additional years added to CRNA programs.
However, this will not happen at least with the goal of achieving such parity. For better or worse MD's have legislated themselves a monopoly when it comes to the PRACTICE of medicine. Furthermore, many people consider the administration of anesthesia (and the management of its associated conditions and underlying etiologies that often accompany such administration) to be the practice of medicine at least to SOME extent. What I think is a more reasonable goal is to seek a situation where CRNA's need only be supervised by an MD not a CRNA. THIS, position can be aggressively defended with rhetorical vigor from multiple perspectives including cost effectiveness. In this paradigm thed CRNA provides the specialized anesthesia knowledge while the MD offers the great breadth of training associated with an intimate knowledge of the whole body, and its diseases.
By the way the INSANE internships which MD's must "survive" are of questionable value with regard to education in my opinion. I have a close friend who is an MD who maintains that the cost of this education is LIVES sacrificed upon the altar of fatigued interns (and residents). Consider, that we have good data to show that operating a vehicle after missing a nights sleep is AT LEAST equivalent to driving under the influence at .10 BAC. Yet interns are routinely pushed to work shifts that often DOUBLE such a threshold. It has more to do with tradition (and cheap labor) for hospitals than it does with education.
Consider also, that JUST because someone as additional education it doesn't necessarily follow that patient outcomes improves. I believe here that the law of diminishing returns applies. Consider this analogy. A respected board certified MDA with five years experience is transpored to the "make believe" land of Oz. In Oz he seeks to return to work as an MDA but is astounded to learn that in Oz his credentials are woefully inadequate to practice his art. You see in Oz (who's people are exceptionally long lived often working into their octogenarian years) the standard amount of education for an MDA is twenty years. Four years undergrad, four years medical school, four years residency and an additioinal eight years in a post residency fellowship.
The good doctor explains the extensive training that HE has had in our world, but is advised by the Oz medical practices board that this is still woefully insufficient for Oz. To allow him to practice (they say) would expose the Oz community to unacceptibly large risks. He is told that he will have to return to school for an additional six to eight years of training (but at least he doesn't have to pay his CURRENT student loans!)
My point with this story is to illustrate that ANY amount of education can be made to seem insufficient when compared to a standard which is higher yet. If human lifespans continue to lengthen with new medical advancements (say to 150 years and beyond) it is CONCEIVABLE that Oz could EVENTUALLY become us.
Far better would be a system that focused on accrued knowledge and skill as opposed to length of training. In my "perfect" world ANYONE could become a MD, MDA or an attorney so long as they passed a truly rigorous examination. This "hyper examination" would probably run several WEEKS in length and would consist of MULTIPLE practical, thoretical, written, and demonstrated skills proficiencies. While ANYONE in theory could take the examination (provided they could pay the several thousand dollar fee) in practice only those who had spent many years in preparation would have a legitimate chance of success. The logic of such a system is that it would focus on OUTCOMES and not process. There would undoubtably be a few prodigious individuals who could pass with perhaps only a years worth of effort (either due to back ground or talent). Conversely, their would be those who despite many years of dedicated effort simply could not master the skills sufficiently to pass. Indeed, if one wanted to account for the "untestible" benefits of extensive education it would only be necessary to mandate higher, passing thresholds for those with less formalized education.
Just one libertarian's dream...Last edit by Roland on Aug 30, '02
Aug 30, '02Are the drugs and the processes and procedures for
> administering the drugs different between the 2:
> a) before graduation (i.e. during school)?
> b) after graduation (during residency as well as after)?
I am sorry, I don't understand the question.
are the processes for administering drugs taught differently between the 2 disciplines?
would there be any case when MDA's are exposed to different scenarios then a CRNA would be during their residency training, it seems to me that after all training it becomes a credentials issue otherwise I would think that after 7 years approx. both disciplines would be equal from an experience standpoint. What I mean is that IF both MDA and CRNA were exposed to the same experiences for approx. 7 years there should be no differance.
Thats why I asked, I'm not sure...
thank you for your time I know its valuable.
Aug 30, '02Tenesma
Thank you for your response. I would also like to thank you for participating in this forum.
In two years, i will get to form my own opinion about the way the relationships work, but you give me validation for seeking this career path. I hope there are plenty more MD's with your sense of levity.
Aug 30, '02Roland,
I would love to see more independence of CRNAs, just as I believe that properly certified midwives and ARNPs/PAs should be able to practice to a certain extent independently... In fact, in some states CRNAs already practice relatively independently of MDAs (instead they have the surgeon "supervise" --- if you know what i mean)... However the management of more complicated surgical patients should and will be left up to MDAs, because of the reasons you stated previously (and that is the more global medical fund of knowledge) .
You mention that MDs have legislated a monopoly... I can't deny that the AMA is a very powerful lobby in washington, but I still believe that what is lobbied for is increased safety. Your example of OZ can't be properly answered as it presents too hypothetical of a situation ... this might be a better example, say your mother develops skin cancer on her face and this is diagnosed by your family practice doctor - now that doctor in turn tells you that she/he is fully trained in excisional biopsies, including certification (and that she/he has done quite a few). what would you do? stay with that doctor or see the head/neck surgeon down the block?
You also mention that, to increase parity between the two professions you would have to lengthen curriculum for CRNAs. That is exactly my point... As far as a generalized statistic that gets thrown around for CRNA curricula regarding amount of clinical OR exposure: approx. 650-700 cases over the course of 1500 to 1600 hours for CRNA trainees --- that equals about 5 months of MDA residency training, with still 31 more months to go... Now a good counterpoint you could bring up would be: do those extra years of training change outcome for patient care? Absolutely... I believe it has affected the decrease in anesthetic death (of course, I can't downplay that advent of non-invasive/invasive monitoring/safer drugs, etc...) from 1:2000 to 1:200,000...
And yes, Internships are insane... And yes, many a night was spent in the hospital... And yes, a lot of decisions were made with your eyes half-closed -- at a lot risk to patients (and ourselves), but the experience of being able to make important decisions under extreme stress is an invaluable experience (hence boot camp for the military - you want them ready for anything no matter what situation/or time of day)
Regarding your libertarian dream of an exam that would provide the end-all permission to practice anesthesia, here is the answer - just have CRNAs take the Oral and Written Board exams for Anesthesia... and thus get their parity with MDAs... (just as long as their clinical exposure to patients is about the same)
Stephanie (aka Chigirl),
are the processes for administering drugs different between MDAs and CRNAs? absolutely not... MDAs and CRNAs use the same monitors, the same tools, the same drugs... the only subtle difference lies in knowing when and why to use the above-mentioned.... would 7 years of practice after training negate the disparity between CRNA and MDA training? it truly depends on the CRNA and the MDA being compared.... I think a CRNA who is constantly testing him/herself with more and more challenging cases, constantly learning outside of the hospital can eventually catch up with a private-practice (unlikely in the academic setting) MDA (quite possibly within seven years) in the setting of the OR - but that isn't the only place that MDAs practice anesthesia (we manage patients in the ICU, we provide pain (acute/chronic/interventional) management, etc...
I hope I answered your questions... and to answer a recent "private e-mail" question i received: yes, i would have total confidence in letting a CRNA take care of me in the OR (depending on my illness and required surgery, of course).
I also appreciate the warm welcome on this forum...
Aug 30, '02You also mention that, to increase parity between the two professions you would have to lengthen curriculum for CRNAs. That is exactly my point... As far as a generalized statistic that gets thrown around for CRNA curricula regarding amount of clinical OR exposure: approx. 650-700 cases over the course of 1500 to 1600 hours for CRNA trainees --- that equals about 5 months of MDA residency training, with still 31 more months to go... Now a good counterpoint you could bring up would be: do those extra years of training change outcome for patient care? Absolutely... I believe it has affected the decrease in anesthetic death (of course, I can't downplay that advent of non-invasive/invasive monitoring/safer drugs, etc...) from 1:2000 to 1:200,000...
thank you this is what I was looking for
Aug 30, '02just have CRNAs take the Oral and Written Board exams for Anesthesia... and thus get their parity with MDAs... (just as long as their clinical exposure to patients is about the same)
can a CRNA take these exams without taking the MDA coursework?
(This is probably a stupid question)
Aug 30, '02here is the bad news: you can only take the boards after satisfying the main requirement 1 year of internship in either medicine or surgery and 3 years of anesthesia (there are further sub-requirements - such as the level of anesthesia training during those three years, satisfactory evaluations, etc.). So no, A CRNA can't take the board exam but i think there may be some ABA test preps out there for the written boards - you can always take a look at those, unfortunately for the oral boards the main thing you need are balls/ovaries of steel
just out of curiosity stephanie, where are you at with your education?
Aug 30, '02Let me say first that I don't belong on this board with all of the people here, and I hope I haven't offended anyone I'm very curious....I am not a Nurse, I'm interested in changing careers, I've been researching Nursing for about 6 months now, including the various specialties. I'm just starting out, I am currently a SW/Process Engineer Sr. I have a BSEE and an MS Telecommunications, PMI Certified, also aquiring ISO9001 Certification as well . (Quality and Process are my specialty)
My goals and priorities have changed I want to enter into the Medical field for many reasons, but the top on my list is to eventually go into research. And it seems to me that in this field either MDA or CRNA there are opportunities for me to reuse my talents gained from my soon to be previous life.
I just wanted to get more of a handle on the politics, pressures, issues of people in the field, ALSO since I am a geeky Engineer, I also believe that the "path to least resistence" is the best path to take, hence finding all of you HERE was a GOLDMINE of information to potentially tap if you were gracious enough to put up with my novice questions. Thanks again :roll
Aug 30, '02First while the Oz parable is hypothetical it does illustrate an important point. Namely, that "education inflation" has become an integral part of our economy in general, and the medical profession in particular. How many MD's are content to graduate as basic GP's? To do so in this day and age would place one in a position to be considered little more than a witch doctor! (perhaps that is hyperbole but just barely). The point is that CRNA's TODAY probably have more education than MDA's did on average say in 1965 or so. This is simply another way of restating the concept which I have already presnted in a previous thread. Specifically, if God were to snap his cosmic fingers and give most people an intelligence capable of scoring at least 160 on standard IQ tests, but some people considerably more intelligence, (perhaps above the 200 limit we are able to measure). Well, under those circumstances todays genius would be redefined as "slow". However, in an objective sense someone with a 140 IQ would still remain quite intelligent. So to is the CRNA's training quite sufficient, and more than capable of providing excellent care in almost any conceivable circumstance.
You are correct that if someone was going to make a decision between praticitoners they would generally choose the person with more education, and or experience. However, this is largely because they lack any other basis for an objective comparison. What I am suggesting is that in fact little if any actual difference in patient outcomes can be expected between an MDA and a CRNA (in the same way that the people of OZ can expect little improvement in the board certified MDA's performance after he completes their mandated additional years of training.) I believe that ultimately artificial intelligence enhanced computer technology will be able to answer this question definitively. We may see the day (and I'm speaking in terms of the next hundred years here) where ALL of our professional actions are monitored and subsequently quantified with regard to their propriety, and efficiency (privacy issues non withstanding). This will mean that many professionals will have statisical measures (not unlike baseball players) which quantify how good they are (at least by the standards of the measurements).
I believe that YOU feel as you say and do not desire to "deemphasize" the use of CRNA's. However, I question if that feeling exists among other MDA's in general. As I stated it is my belief that virtually all organizations (CRNA's included) act to maximize their own self interests either in terms of economic security, and or control. What role do MDA's envision for AA's relative to CRNA's, one of augmentation or replacement? Do you think a CRNA who has not also gone to medical school would ever be allowed to take the board examinations to which you refer?
The best way to keep organizations from stepping over the bounds of propriety is to have informal checks and balences built into the system. This applies also to government, and private enterprise. If power corrupts, then so to does the concentration of too much power into any one group or common interest.Last edit by Roland on Sep 1, '02
Aug 30, '02roland,
I desist... it appears as if you are convinced that a CRNA training is equivalent to an MDA training (yet in a previous post you allude to the possibility of extending CRNA training so as to equal MDA training - very confusing...).... And you have to be careful with what you say... GPs (family practitioners) are not witch doctors, in fact they spend 3 years of training after medical school aquiring their skills in diagnosing and treating the basic ailments of the pediatric, adult and obstetric population. In fact, they are used by many insurance companies as the gatekeepers for further referrals and further medical access. In fact, 3 of the top 3 ranked students in my medical class have gone on to become family physicians...
and to compare the education of CRNAs today to the education of MDAs in the 60s is ludicrous and doesn't support your point... In fact, my elementary education probably would make Pythagoras dumb --- what does that prove? does that make me a greater mathematician?
the fact is that CRNAs do operate independently in the US (and ONLY in the US)... in fact the military considers them to be independent licensed practitioners ... in fact, under quite a few circumstances CRNAs were directly responsible for the president of the United States .... the bickering and posturing between AANA and ASA is a bunch of crap if you consider the status CRNAs have already achieved... and the AAs are truly a non-issue. They are basically MDA-extenders because it has been difficult to hire CRNAs (there is a reason why the salary for a CRNA is so high - shortage of supply), so they (the AAs) basically provide limited anesthesia care and cry for help a lot... and they are never deployed into sick rooms: they do hang-nails, knee arthroscopies, etc. I doubt they present a threat to CRNAs, just as LPNs don't threaten RNs....
i am still trying to figure out what kind of point you are trying to make (other than trying to say CRNA equals MDA)... I still stand by my stance (and i know a lot of my colleagues agree with me): CRNAs play an unbelievable role in anesthesia (for heaven's sake they do 60-65% of all anesthesia in the U.S.) and are an integral part of intra-operative care! But I still disagree with your point that CRNA training can provide excellent care in any conceivable circumstance - they can't and most them know it. How many independently practicing CRNAs provide solo care for transplants (liver,lung,heart), provide trans-esophageal echocardiography during bypass?, can manage ICU patients?, implant nerve stimulators/intra-thecal pumps, invent ventilators (my old chairman created IMV and SIMV), invent the twitch monitor (one of my current faculty), discover cis/atracurium (same faculty as twitch monitor)... the list goes on... but that doesn't take away their valuable contribution to patient care on the whole.
i hope i haven't offended anybody
Aug 30, '021. While CRNA training may or may not be equivalent to MDA training it is probably sufficient. However, it is my contention that the objections of MDA's have less to do with training than their desire for greater control. In addition, it is important to realize that one can always call for ever greater educational requirements it doesn't always follow that benefits accrue to the public as a result of such policies.
2. When I point to "education inflation" and allude to GP's being considered witchdoctors I am being somewhat facetious. Simply stated many more MD's are going on to become specialists than was the case in the past. Even those that elect to practice in "family practice" now often partake in specialized residencies lasting from two to three years. Board certification, in certain specialties can call for considerably more. In short what was considered to be an incredible education just a few decades ago is now seen as insufficient. THAT, is what I am alluding to with the example referring to the MDA in the 60's. It is not difficult to imagine that this trend will continue, and what is considered sufficient training today (in terms of years not qualitatively speaking) will not be so in the future. The MD who chooses to remain a simple "GP" and practice might find acceptence among his peers to be difficult.
3. It is my impression that doctors will try to lessen the current range of practice that CRNA's enjoy. Perhaps, you are arguing that this is not the case (at least in the main) and that Dr's think that CRNA's are just wonderful. You may be correct however the post assumes that this IS NOT the case. In addition, I am suggesting that interest groups often display emergent properties that could not have been predicted from the make up of the seperate individuals within the group. Thus, while most Dr's might truly feel as you and appreciate the contribution of CRNA's AS A GROUP they might still work in ways that are averse to the interests of CRNA's. Again, I might well be mistaken.Last edit by Roland on Aug 30, '02