What do you think (if anything) MDA's will do... - page 3
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 31, '02Tenesma
I think your points are generally right on target.
A word or two about the differences between CRNA and MDA educations. Of course they are different. They have to be. However, and this is a point the ASA does not like emphasized, the paths to those are also different. There are, of course exceptions to every rule, but generally, an MDA follows the path high school to college to med school to residency. The med student does not have any exposure to patients until third year med school. They don't start really doing anything with the patients until residency begins. So, at the start of residency, most MDA's have had little patient experience.
CRNA's, on the other hand, are required to have at least one year experience in the ICU before applying to school. In my experience, two to three years is generally more common. There is a reason that ICU experience is required. Generally, the ICU nurse has to be somewhat more independent, and is used to caring for sicker patients. So, while it is fair to say that the education received by a CRNA is different than that of an MDA, saying only that does not tell the entire story.
My real point is that from what I have seen, the education is not what makes the good anesthesia provider. I know both MDA's and CRNA's who would make me uncomfortable watering my lawn. On the other hand, I know both MDA's and CRNA's I would feel comfortable having anesthetize my 2 year old daughter. Some of the difference is in simple common sense and innate ability. There are people (and I'm sure you know some) who leave me wondering how they manage to get their shoes tied in the morning. Another difference is experience. I think that experience is the real discriminator.
As to the argument between the AANA and the ASA, I agree with you that it is counterproductive. I believe that the ASA is at fault, since they are the ones trying to limit the scope of CRNA practice. The AANA is merely working to protect the rights of CRNA's. I will admit, however, that my viewpoint may be skewed, inasmuch as I am a CRNA. (But, you would have to talk long and hard to convince me that the AANA is at fault for the current spat.) The ASA is trying to convince people in the US, and congress as well, that CRNA's are unprepared to provide anesthesia care independent of MDA's. This stance ignores current events. The fact is that CRNA's are practicing independently, and doing so safely every day. I see the ASA position, then, as more about extending influence, control, and expanding income for MDA's than about patient safety.
In the long run, this fight does more to harm patients than help. If we (the ASA and AANA) could settle this, we could more effectively work together on issues that really do affect patient safety. Given that our organizations have two of the largest lobbying budgets in the medical professions today, we could have a huge impact. The funny thing, to me, is that this fight seems to be occuring at very high levels, irrespective of the relationships currently enjoyed by MDA's and CRNA's who work together every day. I, like you, work in a group with both MDA's and CRNA's. I think our working relationship is great. There is mutual respect, and each of us feels that there are things we can learn from others. Perhaps our professional organizations need to get back to the rank and file membership, to see what they really think needs to be done.
Aug 31, '02that "education is not what makes someone a good anesthesia provider." This question intriqued me. If its not education then what is it? In other words what specific skills do those MDA's and CRNA's who you wouldn't trust to water your grass lack? Perhaps, this is an area worthy of study since IF it could be quantified perhaps curriculums could be modified to account for many of these deficiencies and perhaps saving lives. In addtion, I don't want to end up in that catagory and would therefore like to know what observations cause you to make those conclusions.
Aug 31, '02Roland:
If its not education then what is it? In other words what specific skills do those MDA's and CRNA's who you wouldn't trust to water your grass lack? Perhaps, this is an area worthy of study since IF it could be quantified perhaps curriculums could be modified to account for many of these deficiencies and perhaps saving lives.
In my world you have Technicians, and you have Engineers, most Technicians I know are from the Military and know more about everything to do with Telecom, Electronics, SW development, etc... then some of the Engineers, however in my world the Engineer gets the upperhand because of credentials, plain and simple. I've been in the telecom business for 12 years I understand completely what kmchugh is talking about when he speaks of "experience" I see it everyday. THats why on the other board I searhced, actually I read those 19 pages 3 times for any credible "
either done by the Government or the ANA, or the AMA to substantiate any of the claims made against experienced, seasoned CRNA's. I found none...so far....anywhere but I live on the internet, so I haven't gotten to the library yet.....
Sep 1, '02however Kevin's point may go a bit deeper. Clearly anyone who has graduated from an accredited CRNA program has at least some SIGNIFICANT experience. Furthermore, this is quickly augmented by work in the field. However, he seems to be implying that there are MDA's and CRNA's out there who are a danger to their patients. While I don't doubt this at all, the concept interests me. Specifically, how could such a person manage to gain entrance to CRNA school, graduate, and practice WHILE remaining so inept. Furthermore, I want to learn the kinds of specific behaviors that he witnesses which causes him to make this conclusion. Perception is often reality and its never to soon to focus on fundamentals even as an undergraduate BSN student. My wife and I have given up a fairly lucrative mortgage business to go back to school and become CRNA's. I want to do my best to make sure that we become very good ones.
Sep 1, '02""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. ""
These are GREAT EXAMPLES !!!!
QUESTION: you don't think with equal amounts of experience and research a CRNA could not invent similar products? I do.
Anesthesiology is such a specialized field, I'm finding out, that I can't see after an ample amount of experience either one couldn't contribute to any of the examples mentioned above.
Sep 1, '02Kevin,
I have to take issue with a common misrepresentation... Residents at the beginning have a lot of patient interaction!!! Patient interaction starts already during the first year of medical school with shadowing, the 2nd year the medical student starts assuming the role of student-doctor - caring for patients at a very basic level (usually at small clinics with close supervision and guidance), by the third year the average medical student spends 70 to 90 hours a week with patient interaction, every week of the year, overnight for a 36 hour call, on weekends - this is where the student learns patient management... and this gets refined by 4th year, and then implemented during internship, etc... I have bathed patients, I have transported patients, I have rubbed patients backs while they were throwing up, I have coded patients, I have had family-conferences... I don't understand why there is a drive on the side of the nursing profession to make MDAs out to be not interested in patients (why do you think we went into medicine to begin with?)...
and education does not make the good anesthesia provider??? would you like me to practice without residency? and it is unfair to use bad apples in either field as an argument...I personally believe that anybody who is looking for a rewarding job in anesthesia, but not ready to dedicate a large portion of their life to medicine (either because of family reasons, social reasons) or already have a strong nursing background, should consider becoming a CRNA... this however doesn't give them a soapbox to claim equivalency.
There obviously appears to be a drive by CRNAs to claim their stake in anesthesia by gaining equivalency with MDAs - MDAs are taught medicine and practice medicine, CRNAs started off by practicing nursing and are now performing at a more advanced level of nursing... two totally different ways of approaching patient care.
and Chigirl which studies/claims by the AMA/government do you refer to regarding seasoned CRNAs? and regarding reasearch - how many CRNAs are actively seeking grants for research? I would argue that most CRNAs don't become CRNAs to do research...
bottomline.... I am glad there are CRNAs out there, I am saddened that there are petty fights between our representing societies, I am still trying to figure out why it is so important for CRNAs to downplay MDAs, to claim equivalency (i can only wonder if there are insecurities here?)...
Sep 1, '02"I am still trying to figure out why it is so important for CRNAs to downplay MDAs, to claim equivalency (i can only wonder if there are insecurities here?"
I wonder the same thing...Why do you consider the statement that a CRNA can provide anesthesia to a patient equally as well as an MDA to be "downplaying" the MDA. Both provide a high level of care.
While there are facilities where the practice is limited as to type of surgery, there are an equal number of facilities where it is not. All over the country, every single day there are complex cases and complex patients who are receiving anesthesia from a CRNA.
As you know MDA supervision frequently means, the MDA is in the office with absolutely no input regarding the anesthetic care. If CRNA's are not capable of dealing with the more complex patients then why does this practice continue? Why has there not been an outcry regarding the bad outcomes in complex patients whose anesthesia was provided by a CRNA?...My answer to that would be that it is because the CRNA's are providing good anesthetic care to these patients.
Give me an example of any patient or case that a CRNA does not have the ability to perform well. Just one.
Also an example of a time when an anesthesiologist would pick a drug for the patient, that a CRNA would not have picked due to educational differences.
I am not of the opinion that my education is the same as yours. But, I am of the opinion that my education allows me to provide anesthesia to the same level as you do.
Truthfully if I cannot provide anesthesia that is as safe and effective as the anesthesia provided by an MDA, then I have no business giving it at all. If this were the case then it would mean that we are allowing patients to receive substandard care. And that would bear out in the research!
Sep 1, '02that discussed a proposed Massachusetts law that would place hard PRICE controls upon the wage that an AGENCY nurse could earn in that state. Aside from being bad public policy (anyone with a basic economics course should understand that price controls will create or exasperate existing shortages in the same way that price subsidies will worsen surpluses) It is this sort of stealth legislation probably pushed by interest groups backed by large health care institutions that CRNA's must fear being implemented against them. What's more if this legislation actually goes through (assuming that the post is legitimate, I haven't gone so far as to validate the information presented yet) CRNA's must truly wonder if they wouldn't be impotent to stop similar proposals. After all the MA proposal would affect ALL nurses and thus should face opposition from every major nursing interest group.
This proposal demonstrates the necessity of CRNA's being PROACTIVE in protecting their interests. I started this thread with the supposition that MA's as a group perceive CRNA's to be a threat to their interests. IF I am correct in this proposition then it follows that they will act in ways designed to defend those interests. Therefore, the question remains what are some of the best ways for CRNA's to counter such actions?
Sep 1, '02Tenesma-
I think you have made some very valid points and agree with what you say for the most part.
However, I wonder if it possible that some of you have misinterpreted what Kevin had to say about not trusting some MDA's or CRNA's to "watering his lawn." The way I interpreted that was to mean that even though both types of professionals obviously have had the required education does not mean they have the common sense or bedside clinical skills to provide good care. They may be able to answer any question correctly on paper, but translating that knowledge into application of clinical skills is another thing. In my experience, I have on more than one occasion met a nurse who was very intelligent, but couldn't apply her knowledge to bedside care. In other words, hands on clinical skills and application of knowledge at the bedside is very different than reading a book and taking a test. Critical thinking skills must be present and must be utilized very effectively at the bedside and not all people have as strong critical thinking skills as others. So, just because someone has achieved the education requirements doesn't always mean they are adept at providing hands-on care to patients. I know there are clinical requirements for graduation, but it is very different doing clinicals in a learning environment than actually practicing autonomously on your own license. As far as the MDA vs CRNA controversy, I think there will always be a controversy. It's just like the controversy with MD's and PA's and FNP's. I have heard some PA's argue that they were trained by MD's, took the same A &P's with MD students etc., and can treat patients the same, but they can't work independently. Some PA's don't feel FNP's have had equal training to the PA and feel that it is unfair to allow FNP's to work independently. In my personal opinion, I believe that the root of the controversy surrounding all of these issues is not a question of safe, effective patient care provided by Advanced Practice Nurses, but a desire of the medical community to control nursing as maybe it once was. Again, the training and requirements for the MDA vs the CRNA are different;but, nevertheless, both provide excellent care to patients with safe outcomes. I think there is a lack of respect for each profession on both sides of the spectrum-most MDA's don't like having a "nurse" work independently and then some CRNA's think their education is equivalent to that of the MD and it's not. Bottomline is the MD receives a much broader knowledge base on general medicine than the CRNA typically does and I can see where that knowledge can come into play when providing anesthesia care to some difficult to manage patients. Don't get me wrong, I am not saying that CRNA's with a lot of experience can't manage the same patients that were mentioned above by Tenesma as being patients not typically managed by CRNA's because I disagree with that point. I think that some CRNA's who have a lot of clinical knowledge and experience can provide care to the equivalence of some MDA's, that is true and I hope one day to be one of them, but the fact still remains if a CRNA wants to be considered an equivalent provider to the MDA in the eyes of society, then they should go to medical school. In addition, I think is acceptable for CRNA's to work independently in most situations. I also think that MD students who piss and moan about how much money CRNA's earn and that they shouldn't be able to practice independently should take another look at the career choice they have chosen because I think it is more of a jealously thing than anything else.
Sep 2, '02are a very good way to protect CRNA interests. However, I am speaking to strategy and tactics. In other words WHAT things can those groups do to effectively combat equally effective interest groups on the "other side". Perhaps, this is an excessively conflict orientated perspective, but I believe it to be a valid portrayal of the situation as it exists. It might be possible to ameliorate this situation via some sort of trans CRNA/ MDA organization that looked at the problem as something OTHER than a zero sum game. However, such an ideal no matter how noble doesn't seem to be in the cards presently (at least I'm not aware of it if it is).
Instead, we have a situation where MDA organizations seek to further limit the scope of CRNA practice, and CRNA organizations are seeking to expand their mandate (or at least maintain the purview which they currently enjoy). A good (albeit imperfect) analogy would be the situation which exists between Handgun Control Inc. and the NRA. Each organization seeks an outcome completely unacceptible to the other and there is very little room for negotiation. The issue of gun control will likely ultimately be decided by the group which can most effectively muster resources in the most efficient manner so as to sway public opinion in their direction or the side which displays superior intellect and cunning in furthering their cause.
CRNA's MAY be outgunned in terms of financial resources, but it doesn't mean they can't prevail if they utilize superior tactics. I have already suggested the funding of studies to further demonstrate the safety, efficacy, and cost effectiveness of CRNA's. In addition, I would submit that aggressive public relations campaigns might be useful. Alliances with HMO's, insurance companies and hospitals, motivated by their desire to control costs would also be logical. Such alliances could be used to push for even greater independence for CRNA's than they currently enjoy (even if the real goal is only to maintain the status quo). Aggressive offense is often more effective at protecting one's turf than even the best defense.Last edit by Roland on Sep 2, '02
Sep 2, '02roland... i was scratching my head about what you said in your last post: i wish i could come up with a good concrete resolution to the issue, but the truth is I am just as frustrated with the whole process and I don't think there is going to be a good answer for a while... i think it would be interesting to see what would happen if the AANA and ASA merged and became an anesthesia-provider organization (think of the possibilities!!!). however, i doubt that would happen for a long time to come.... too bad.
i hope everybody has a great labor day weekend