[Trauma Tom]

Loisane,

Very interesting. It never occured to me that MDA's perspective on collaboration would be different than our own. One of my main reasons for becoming a CRNA, besides all of the obvoius reasons that have been repeated numerous times on this board, was the enhanced role of the CRNA in dealing with patient care. Your statement that "The 'ologists don't really see us as different from other non-specialized nurses, while CRNAs perceive the difference to be quite significant," drives home a point that I really was not aware of. I just assumed that anesthesologists did see us different from other non-specialized nurses. If in fact they don't, it becomes easier to understand their treatment of us in the past. While this does not excuse their behavior in the past, I can now begun to understand it. Tenesma, I would be interested for you to comment on this if you are so inclined.

Trauma Tom

Originally Posted by loisane

If we're going to talk about collaboration, I have to jump in with both feet. This is a topic near and dear to my heart. And one I probably know dangerously too much about, so someone might have to remind me to shut up when you have heard enough!

Yes collaboration does have a dual positive/negative meaning. This was quickly recognized by this bright bunch <g>. The most significant thing I have learned about collaboration between nurses and physicians, is that each side has a very different perception of just what constitutes collaboration.

Nurses have been studying this for over three decades. There was a seminal work published in 1967 that coined the phrase "Nurse/Doctor game", that described how nurses got doctors to order what patients needed by convincing the doctors that it was their idea. Multiple studies have followed. Recently, there is even a little being published by the medical community.

In all these studies, no matter what the setting, or how collaboration is measured, there is one consistent trend that (to me) is quite striking. There is a difference in the level of collaboration occuring depending upon whether the answer is coming from the participating nurse or the physician. Physicians think there is more collaboration occuring than do the involved nurses.

I think nurses have spent way too long on the goal of "getting physicians to collaborate". We aren't going to make headway on this until we figure out why the two disciplines see things so differently. We keep trying to devise ways to get them to do something, that they think they are already doing. We have to get on the same page, and start talking the same language.

Here is my theoretical explanation. There are actually different forms of collaboration. The type most nurse think of is "interdisciplinary" in which the involved parties work together from postions of equal power. Physicians view collaboration as "multidisciplinary", in which the involved parties work together, but final authority rests with the physician.

Granted, most of this work has been done in "basic nursing", but the studies done in ICU setting show the same patterns. Until specific studies are done in anesthesia, this is the information we have to build on. While CRNAs might view collaboration differently than other nurses, I think there is not much reason to think anesthesiologists will be that different from other physicians. Indeed, that might be a reason for the level of conflict in our specialty. The 'ologists don't really see us as different from other non-specialized nurses, while CRNAs perceive the difference to be quite significant.

I don't intend to sound like I am accusing physicians of being self centered, and not playing fair. I think their attitude is grounded in their professional belief system. Medicine has a strong value that the patient is their personal responsibility. They have a personal relationship with that individual patient. Their value system mandates that the patient "deserves" physician participation in every aspect of the patient's care. For the physician to share that responsibility with other health care team members does not fit their value system.

(None of this is to discount the influence of money, governmental regulations, etc. That is just another discussion, for another time. For that discusssion I will wear my "Political/professional activist" hat. Right now I have on my "Abstract thinker/academic/researcher" hat.)

Better get off the soapbox now. For those of you that find this as interesting as I do, I hope to be continuing this discussion in more public venues in the (hopefully) forseeable future!

loisane crna

[deepz]

It's not easy to know where to start with such a scattershot .....

Originally Posted by Tenesma

deepz...

you are right... as residents we got 2 15 minute breaks and 1 30 minute lunch break every day - and on call we got a 30 minute break every 6 hours (on average)... so you are right, you can deduct 10 hours a week for breaks ...
by the way, the ACGME passed a rule a year or two ago that limits the amount of hours worked in the hospital to 80 hours a week - probably because too many residents were sleeping, eating and watching TV.... Just curious, when was the last time you worked 80 hours a week?

my statement wasn't off-base - it was based on fact... the class of US-medical school trained residents starting in 1996 was only 300!!! out of 1200 or so spots!!! that was a huge drop based on the wall street journal scare and the JAMA scare... Almost all specialties except for the most competitive (ophtho, derm, urology) have a 20-40% of FMGs. I find your comment to be off-base somehow correlating dregs of medicine with FMG.... I think there are many fantastic doctors who happen to be FMGs. But I can say with certainty based on board results, atttrition rates, etc, that the years of 1996-1998 were filled with FMGs that were scraped from the bottom of the barrel....


while i agree that the cream of nursing can be found among CRNAs - i find your comment that the dregs of medicine to be somewhat pathetic... I truly am very, very sorry that your exposure to MDs has been so horrible...

"Just curious, when was the last time you worked 80 hours a week?"

Why the personal angle? Is that any of your business? As it so happens, by your definition (being on call) I worked *exactly* 80 hours in six days just this past week. No whining here, nor bragging about it either. BFD.

I also once spent a decade at a little county hospital, solo, on call 24/7/365; my work week then, by your definition, would have been 168 hours per week. But BFD -- that'd be bogus.

So, what's your final count then, Doctor? Subtracting 10 hours of breaks a week must put quite a dent in your grandiose former claim of 10,000 hours of training for the average MDA. 8,500 now? How about subtracting your considerable hours spent on the internet? Yikes!

"I truly am very, very sorry that your exposure to MDs has been so horrible..."

Why the exaggeration again? So horrible as what? How would you presume to judge my work history?

As it happens, I spent that last week with a group that includes two top-notch MDAs, with whom I share a long-standing collegial respect. We practice in parallel, without stupervision, and consult with ease back and forth. Do we talk anesthesia politics? HELL NO. They do not ascribe to the radical put-down philosophy espoused by A$A leadership.

However, a few months back there was a locums MDA at that institution (who happened to be an FMG) who was so poor that he could NOT (I'm not making this up) even start his own IVs. "Never been good at that," he told me. IVs!! Makes one question whether he was an impostor. No, he was not. He was an anesthesiologist, paid thousands of dollars a day.

And there exist facilities out there in the heartland where hospitals pay such MDAs as him 200 and 300 thousand dollars a year to merely 'be available' to 'supervise' CRNAs, whether the MDA is present in the hospital or somewhere else in town.

No clothes! Nekkid! That emperor got no clothes on!

[loisane]

Originally Posted by Trauma Tom

Loisane,

Your statement that "The 'ologists don't really see us as different from other non-specialized nurses, while CRNAs perceive the difference to be quite significant," drives home a point that I really was not aware of. I just assumed that anesthesologists did see us different from other non-specialized nurses. Trauma Tom

TTom, your post reminds me that I should make it clear that I am speculating this to be true. I don't have the data (yet). I am very sure I have encountered this attitude among some individuals. But there may be other individuals with very different attitudes.

I believe the root source of all this "politics" that started this thread, is the difference in definition of the ACT. Organized anesthesiology recognizes no role for autonomous CRNAs. All CRNA delivered anesthesia must involve an anesthesiologist. While some anesthesiologists may feel differently (as deepz and others have described) as long as this is on record as the position of the profession, it is going to affect our interactions with them.

loisane crna

[Tenesma]

i don't know if i can speak for all physicians, but CRNAs are not considered equal to other non-specialized nurses.... they are considered to be superior to non-specialized nurses (extra education, etc...) However many physicians i know (especially non-anesthesiologists), consider CRNAs to be equal to other specialized nurses: ie: NPs.

[alansmith52]

I just noticed how well my apex compared to base ventilation bate and catch worked.
the simple mind thinks of the V/Q ration right away?
now if i could just teach one of my attendings about how ventilation favors the more distensible base. (or more dependant lung)
lol tee heee

[TennRN2004]

Originally Posted by Tenesma

i don't know if i can speak for all physicians, but CRNAs are not considered equal to other non-specialized nurses.... they are considered to be superior to non-specialized nurses (extra education, etc...) However many physicians i know (especially non-anesthesiologists), consider CRNAs to be equal to other specialized nurses: ie: NPs.

I am glad to hear physicians recognize the advanced role of nursing. Those who consider FNPs/CRNAs/CNS all equal as advanced nurses are not wrong in that each of these are advanced practicing nurses with more education and a broader clinical responsibility in their field. However, they are not the same, just as a pulmonologist and neurologist are the not the same. Both of these physicians may specialize, but they have different focus of what they do, just as the advance practice nurses can choose to specialize.

Regarding Loisane's comments, I found that perspective enlightening for what goes on in the profession of anesthesia. There defninitely is a lag of communication in regards to collaboration. In the ICU setting, I can tell you, what you describe makes perfect sense. The approach to care is multidisciplinary, but the physicians still want to be head of the team.

In regards to anesthesia however, I think there is another root problem other than the different definitions of collaboration. It has been discussed here before as well. The huge problem I see is how do we define anesthesia? Is is medicine, is it nursing, or can it be BOTH? The problem many anesthesiologists have with CRNAs (being autonomous) is that they see them wanting to practice medicine without obtaining a medical degree. I agree that Loisane's comments about physicians thinking every patient deserves a physician and the patient is a physician's responsibility are right on target. While this goes a long way to explain why there are problems between the nurse/doctor relationship, it also points out doctors have a lot of power/control and will not willingly give this power up, if only for the reason that it is their responsibility to be in control.

I think both sides have alot of compromise before there will be any resolution. However, the profession of medicine cannot place boundaries on the profession of nursing and not expect a cry of injustice. Tenesma, I do not say any of this as offensive to you, or any other anesthesiologist, but honestly, when looking at studies showing safety of supervise/unsupervised nurse anesthetist roles, can you say that the ASA is not biased and would not be capable of leading outcomes in favor of CRNAs needing supervision?

I know there are some CRNAs out there who should flat not be practicing independently, but that coin can also flip to include anesthesiologists who are not safe practioners. This post has definitely taken on a political/activism tone as Loisane did not intend hers to be, but I consider this the reason why there will be struggle in anesthsia.

When CRNAs view themselves as top notch practioners, and the highest acheivement in their profession, it is a slap in the face to be reminded over and over they are considered inferior to 'ologists, whether this inferiority is warranted or not. The oppinions are many anesthesiologists are warped by the ASA stance on keeping anesthesia a medical turf only.

[BigDave]

Just my two cents...as a nurse practitioner and a CNS--the amount of dedication, commitment to the profession and absolute dead on "have to do the right thing every time" places CRNAs at a much higher level of practice than other advanced practice nurses. There is a widely regarded saying in medicine that 1/2 of the patients will get well regardless of the MD/NP/whoever intervention is made. Do us in this forum consider the same in the OR?

As far as education goes, I worked two days/week in a cardiac surg ICU, restored a 67 Mustang, we had a new baby, I took extra classes for a dual-degree...and still got a 4.0. Any of you SRNAs feeling any of that freedom?

[air]

One thing is certain, Alansmith is pro-nursing.
Alan, should you care to run for office at any of our professional organization, you have my vote.
I do not necessarily agree with all that you espouse but you write with convicted passion and you stick with it, in the end that's all that matters.

[Brenna's Dad]

All very interesting stuff.

Regarding my very early comment regarding the mechanical aspects of anesthesia.... I was not necessarily referring to advanced clincal skills such as the insertion of lines, nerve blocks, etc., but rather the more mundane aspects such as titration of medications, mixing of drugs for infusions, IV catheter placement, vigalence, etc.

The residents I have observed are trained to assess patients and give orders for nurses to follow. I havent seen any physicians mixing and titrating drugs for example or spending long hours at the bedside observing patient trends. This is what I believe must be the hard work for physicians when learning aneshesia (and please correct me if im wrong). This is where critical care nurses have the benefit when learning anesthesia. Physicians have the benefit of a thourough medical education of course.

[deepz]

Originally Posted by Brenna's Dad

......The residents I have observed are trained to assess patients and give orders for nurses to follow. .... must be the hard work for physicians when learning aneshesia ......

Yes, BD, as noted previously on other threads, most residents spend the first two years attempting to learn how to act like a nurse and actually DO hands-on patient care. Many just don't get it. Some consider it beneath their dignity.

Therefore, CRNAs will never lack for demand for their services.

deepz