How do CRNAs/SRNAs benefit anesthesiology residents?

[HawaiiRN]

I was searching for information on the Wake Forest CRNA program and happened upon this information on the Wake Forest anesthesiology program. Dr. Royster has an interesting view on how CRNA's/SRNAs affect and benefit the anesthesiology residency program at Wake Forest.... " Another benefit of nurse anesthesia in a residency training program is the availability of nurses to relieve residents at the end of the day, so that residents can do their preoperative assignments and get home at a reasonable hour, have dinner with their family....." http://www1.wfubmc.edu/anesthesiology/Education/Residency/FAQ.htm

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[BigDave]

Great post Kevin. I need to buy you a few beers some day for working hard to keep this forum grounded. I am new around here, and not a CRNA/SRNA (yet?), but I do enjoy hearing valuable comments from other anesthesia providers, namely tenesma, georgia aa, and tejasdoc. Yes, it looks as though there is a lot of misinformation, bias, and maybe fear of erosion of professional position. Similar to what you said, we are all going to have to work together and find a solution to the increases in demand or just start living in the OR...

I have limited personal knowledge of the MDA/CRNA friction. I always thought it was the surgeons that created all the stress. That is the reason that I went to NP school rather than CRNA school...big mistake, and thanks Dr. C---(you jerk!).

It is good to know that there are all these "issues" between MDAs and CRNAs, or more correctly, the ASA and AANA. Better than being blindsided?

Am I wrong, or do the practicing CRNAs on this forum seem to have the least negative things to say about MDAs?? Are they just being civil, or did they find a practice setting that provides harmony, rather than strife?

thanks,

Dave

[deepz]

"Anesthesia is unique ... our unique role is supportive care." Not true.

.....To say I don't diagnose and attempt to cure, even though I may only treat a condition, belittles what I do, and that's offensive.

It appears from other posts that TD does NOT accept anesthesia as ALSO a practice of nursing, and therefore insists it to be exclusively the practice of medicine, even though the ASA itself has recently amended their official party line to recognize anesthesia as ALSO the practice of nursing. Not much to discuss there. As is said, "We don't need no stinking badges."

Regarding the unique nature of surgical anesthesia, I simply cannot comprehend how TD can categorically deny that anesthesia is supportive, not curative. That TD, as a perioperative specialist, may also have other duties outside the OR, beyond surgical anesthesia, duties which mean TD attempts to cure a patient's problem, that's a separate issue. Surgical anesthesia itself cures nothing, seems to me; I'm just getting them through their procedure and out to PACU best as I can. Anesthesia facilitates the efforts of others in their attempts to cure. Yes, it is a secondary role, and it always will be. No problem there for me. Sorry if that offends TD, or if TD finds it belittling to play second fiddle.

OTOH, does TD repudiate the ASA habit of invariably using the put-down term "anesthesia nurse" to belittle CRNAs?

deepz

[loisane]

The simplest answer I can give is that I think anesthesiology is the practice of perioperative medicine and medicine is practiced by physicians.TD

Sigh, yes this is it in a nutshell. IMHO, all of our professional disagreements can be distilled down to our divergent opinions of the ACT. Organized anesthesiology has defined all anesthesia as the practice of medicine. So their definition of nurse anesthesia is that CRNAs practice delegated medical acts. Of course, nurse anesthesia disagrees.

It might interest you to know that all the court cases, and legal precedents have favored the nurse anesthesia definition. And to know that not ALL anesthesiologists agree with the ASA party line. Obviously, if some anesthesiologists are working with CRNAs in ACTs where they accept the CRNA as a full participitory member of the team, they have rejected the ASA definition, at least on some level.

I know you disagree with all of that. But if I remember, you said you are early in your anesthesia career, a new resident? You will be forming your own values and opinions over the coming years. The very fact that you are here indicates to me a willingness to keep an open mind. I encourage you to always try to see the big picture, and decide for yourself.

loisane crna

[loisane]

I don't know how referring to you as a nurse marginalizes you, you're a nurse.

I think there's a discussion about this right now, something to the respect of "Are CRNA's ashamed of being nurses?" Probably interesting, haven't gotten too into it, don't think I have anything to offer that discussion.

TD

Actually, I encourage you to check it out. I started that thread, in an attempt to tell some history, and how it is still affecting all anesthesia practice (mostly nursing, but is bound to affect medical anesthesia also). I think it has alot to do with our discussion here.

There is another thing here that physicians fail or choose not to see. The public and the media have dumped all of nursing into one big bag. As an example, is anybody else a Survivor junkie? Tina, who won one of the seasons, was always identified as a nurse. You know her real job title? She is a NURSES AIDE!

So even RNs, and most especially APNs (advanced practice nurses, master-prepared CRNAs, midwives, clin nurse specialists, and nurse practitioners) have learned to be tenacious about hanging on to their titles, in order to not get lost in the mix. Seems like such a small thing to ask of our collegues in medicine, to get our titles right. Once they are educated to the issue, and still hang onto the "anesthesia nurse" phrase, it usually makes me questions their motives a bit.

loisane crna

[Sheri257]

As a layperson, I'm a little confused by the title argument. I could understand the problem if people referred to CRNA's as just nurses. But I can also understand how people might say "anesthesia nurse" instead of "nurse anesthetist."

The word "anesthetist" doesn't roll off the tongue that easily with all of those t's ... it's almost a tongue twister, of sorts. Are you sure it's meant to be insulting? Or, is it just easier to say "anesthesia nurse" in conversation?

And why would it be insulting? I'm just trying to understand why CRNA's find this objectionable.

[loisane]

And why would it be insulting? I'm just trying to understand why CRNA's find this objectionable.

I believe there is a difference in the use of the phrase between a layperson and a health professional.

I was talking about the use of the phrase among anesthesiologists. They are perfectly capable of pronouncing anesthetist.

Whenever an anesthesiologist routinely and persistently refers to me as an "anesthesia nurse", I always wonder if there is a hidden agenda. Perhaps they are deliberately emphasizing the traditional hierarchial, controling relationship of physicians over nurses. It says to me, that this anesthesiologist does not view me as a collegue or a full team member. They expect to give orders, and expect me to follow them.

I suppose it is possible that there may exist an anesthesiologist who uses that phrase, and does not mean it in that way. But I have yet to meet such a person.

The anesthesiologist who I have worked with in positive, collegial team environments, do not refer to me as an "anesthesia nurse".

loisane crna

[TejasDoc]

It appears from other posts that TD does NOT accept anesthesia as ALSO a practice of nursing, and therefore insists it to be exclusively the practice of medicine, even though the ASA itself has recently amended their official party line to recognize anesthesia as ALSO the practice of nursing. Not much to discuss there. As is said, "We don't need no stinking badges."

Regarding the unique nature of surgical anesthesia, I simply cannot comprehend how TD can categorically deny that anesthesia is supportive, not curative. That TD, as a perioperative specialist, may also have other duties outside the OR, beyond surgical anesthesia, duties which mean TD attempts to cure a patient's problem, that's a separate issue. Surgical anesthesia itself cures nothing, seems to me; I'm just getting them through their procedure and out to PACU best as I can. Anesthesia facilitates the efforts of others in their attempts to cure. Yes, it is a secondary role, and it always will be. No problem there for me. Sorry if that offends TD, or if TD finds it belittling to play second fiddle.

OTOH, does TD repudiate the ASA habit of invariably using the put-down term "anesthesia nurse" to belittle CRNAs?

deepz

As for the practice of medicine, practice of nursing subject. We're never going to agree, I didn't expect we would, but I didn't want to ditch the question, since it would seem as though I am dodging it to save myself from an uncomfortable position. We can disagree on this one in a civil manner deepz. Though, I have to say that I think even the law agrees that anesthesia is the practice of nursing and medicinem, as far as I know. I think the ASA still thinks anesthesiology is the practice of medicine though, you should visit their website, the following page states it pretty clearly, but maybe it's out of date, if you could point me to a reference deepz, I'd appreciate it. I might be wrong, but you'll have to excuse me for not believing you, just because you said so.

http://www.asahq.org/patientEducation.htm

I don't play second fiddle in the OR deepz, I play a different fiddle, and I'm totally cool with that. If I had a sensitive ego, I wouldn't have gotten into anesthesiology. While in med school, I told an older surgeon, "I don't think young surgeons think much of anesthesiologists." He said to me, "Young surgeons don't think much of anyone but themselves." I laughed and it gave me a perspective on ego. And I'm sure you've saved your share of surgeons from hurting a patient. For now, I'm just going to concede your point on the "curative" role of anesthesia. I think Tenesma once posted all the things you can cure with anesthesia, it's out there if you want to look for it. But I can't concede that anesthesiology does not diagnose and treat with a very important critical care medicine component.

The ASA and the "anesthesia nurse" comment, especially if being said in a derogatory manner, no, of course I cannot condone. But show it to me, show me where an official ASA document uses "anesthesia nurse" in a derogatory manner. It might be out there, who knows? BUT, I think the difference between an anesthetist and an anesthesiologist is lost on the VAST MAJORITY of the population. I'm just guessing, don't have any actual facts to support this, but I would bet that your average college educated American, if asked what an anesthetist was, would say "The doctor who puts me to sleep when I have surgery." They're not being rude, they just don't know. If you say "anesthetist" to a patient without "nurse" in front of it to exploit their ignorance, shame on you. Anesthesia nurse and anesthesia doctor are REALLY simple to understand, and if you use those terms to belittle those who work with you, again, shame on you. But if you use them to explain what might be a difficult concept to a less than savy patient so they can understand the members of their anesthesia care team better, no harm. But I'm going to always make it a point to say nurse anesthetist, now I know it's an issue, and I don't want it taken the wrong way, which it might. All honesty, I want to give you all the respect you deserve, and I think that saying 'nurse anesthetist' does give you credit for a lot of education and experience.

As a response to Kevin McHugh, REALLY well said. You had a really thought provoking post on the SDN before too right? We might not agree on everything, but I enjoy reading your opinions, and I think you really make some great points.

Loisane, yep, I'm a new resident, and I'm trying to keep an open mind but to be honest, it's struck me as a fine idea to just find myself an all anesthesiologist practice when I'm done and not have to deal with a lot of this. The supervision thing is tough I imagine, if you're an anesthesiologist, and you respect the CRNAs you supervise (think they're well educated, capable, make good clinical decisions, have a wealth of knowledge and experience), you give them a lot of autonomy, then I see them coming to boards like this and saying you have donut breath and are getting rich and not doing anything. They never say anything to you, but theres an undertone of resentment that exists in that relationship. If you micro-manage, just the opposite, the CRNAs won't think you respect them, that you think their education and experience are worthless and that you need to hold their hands or they'll screw something up. Again, they're out on a message board saying how the anesthesiologists think they're incompetent technicians and the resentment, still there. Sometimes I think that if I can avoid it, I should. Oh well.

TD

[Athlein1]

Tejas,

Thank you for editing your post (not only the personal information part, but also the content about the MDA thing as well as the JUST NOT THE SAME remark). I think you realized that those portions were also inflammatory, and for that, you deserve recognition that you are trying to participate in a level-headed discussion in a tactful manner.

I find it regrettable that Tenesma has decided to stop posting. I take responsibility for the part my post played in that decision. My response to his post had a comment that could be construed as personal, which is why I immediately removed it.

I really do wonder what interest physicians and AAs have in this board, though I absolutely agree that their posts are often interesting and thought-provoking. At the same time, I believe they can also be inflammatory and condescending, whether intentional or not. It is naive to think that we would welcome statements describing anesthesia as the practice of medicine and espousing mandatory medical supervision for anesthetists on a pro-nursing, CRNA message board.

If statements like these don't get our hackles raised, then how can we possibly hope to maintain the broad scope of anesthetic practice we enjoy today? Modern practice evolved as a direct result of the hard-earned efforts of nurse anesthetists who spent their entire careers working to receive recognition and fight for our rights to practice anesthesia. To acquiesce to efforts to define anesthesia as a practice of medicine or otherwise limit the scope of nurse anesthesia practice is a disservice to the profession - past, present, and future, even if such is undertaken with the aim of fostering improved relations between the two professions.

[loisane]

it's struck me as a fine idea to just find myself an all anesthesiologist practice when I'm done and not have to deal with a lot of this. TD

Well, that is certainly one of your choices. But, I believe there is another as well.

IMHO, the "donut breath" type comments are aimed at anesthesiologists who do not direct, and yet charge for it. CRNAs who work in these environments are capable of non-directed care. That is obvious, because that is how the care is being delivered. And yet, they are not respected for the level of that care.

Another solution is to not charge for direction, if you do not give it. Charge as supervised, or non-directed (two other Medicare charge categories).

If an anesthesiologist opinion on CRNAs is they "think they're well educated, capable, make good clinical decisions, have a wealth of knowledge and experience", they can practice in ACTs where CRNAs are not directed. The ASA wants you to believe that your only choice is direct CRNAs in a ACT or work in a MD only practice. You DO have other choices.

These ACTs exist, and these non-ASA anesthesiologists exist. I wish they would become more active in their association. They are invisible in our current turf battles. Your job as a resident is to look for role models, and find the ones that fit your personal beliefs and values. It is my sincere hope that more and more anesthesiologist residents will come to question some of the traditional ASA mantras. Obviously, that is my pro-nursing postion. But I honestly believe that it is the best course for the care of our patients.

I may not sway your opinion. But I challenge you to at least look at your choices critically.

loisane crna

[Brenna's Dad]

Tejasdoc,

I just wanted to emphasize that my comment, relating to the MDA sitting in the office getting rich, was ONLY intended to demonstrate the power of words and provide an example of a phase an anestheiologist might not appreciate.

I thought I had made that clear, but my apologies if I did not.

Believe me when I say that I have noting but the upmost respect for most of the anesthesiologists I work with and the anesthesiologist profession as a whole.

[deepz]

......I think the ASA still thinks anesthesiology is the practice of medicine .......

Undoubtedly. So do I. But to categorically deny that anesthesia is ALSO the practice of nursing flies in the face of reality. It is both. Of course the ASA does not represent all anesthesiologists, but for years the radical leadership of the ASA (Eg. Dr John [did 300,000 cases by myself] Neeld) not only insisted that anesthesia was solely and exclusively the practice of medicine, they also refused a dialog with the AANA unless and until the AANA acknowledged the primacy of that ASA policy.

Then last year a funny thing happened. The new leadership of the ASA opened the possibility that the two groups could dialog with *no* preconditions. That overture had to be approved by the ASA Delegates, I believe. And the two groups have now had a number of meetings. More info available at aana.com

deepz

[Kiwi, BSN, RN]

I regret that Tenesma, or any other MDA would cease posting here. AAs as well for that matter. There are few on this board who "scoff" their comments, but many of us who at least want to learn what they have to say. Undoubtably, there are veteran CRNAs who have experienced emotional torment, unkindness, and even humiliation from smug docs. Here, at least there is a safe harbor for learning and conversing and disagreeing - whatever. SRNAs can carry on the torch and hopefully reconciliation can be made step by step between MDAs and CRNAs.

But I stop keeping an open mind if the poster is not pro-CRNA. And yes... MDAs, and AAs can be pro-CRNA.