Should Anesthesia Be an only MD Profession

Roland · Feb 28, 2004

Well as you may know I believe that conspiracies are the rule rather than the exception ( I always thought that If I had a fancy Ph'D in Psychology or Sociology I might write a book entitled something like The Conspiratorial Animal about how conspiracies are fundamental to many sociological, political, and economic processes from the very dawn of history to modern America). However, IF this is the case the best thing that CRNA's could do would be to undertake aggressive efforts to educate every active CRNA up to standard who will undertake the training. In addition, efforts could be made to encourage anesthesists to practice in CRNA groups rather than MDA groups (or working in a setting where they will be under primarily MDA supervision) in those areas which will permit this arrangement. For me the bottom line is that OF COURSE MDA's will seek to erect both overt and sublime barriers for CRNA's. It's not because they are bad people or that they are less than professional. It's just the way things are done in business, virturally EVERY business from appraisers to zoologists. However, that doesn't mean that CRNA's should just lay down and let it happen.

Oldsalt · Feb 28, 2004

Roland thank you for your post:

Though much can be gained from seminars - they don't offer what actual training provides: numbers in real life situations- this must start in one's training - not ad libbing once graduated.

Furthermore, the degree of use this knowledge can be utilized is somewhat hampered if one returns to a limited scope practice to begin with.

Book/Seminar knowledge is completely inadequate if not combined with experience and repetition. I don't mean to be sound pretentious, but the reality is, is that one does not become proficient overnight at one of these seminars.

Many are insightful, educational, and worthwhile - but they do have limitations

Regards..

:)

Brenna's Dad · Feb 28, 2004

I agree Oldsalt. This education must take place in your graduate education.

It is my understanding that it is with this in mind (and the ASA difficult airway algorithm) that the AANA is mandating fiberoptic didactic and instruction be incorporated into CRNA education.

Kason · Feb 28, 2004

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.

gaspassah · Feb 28, 2004

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.

Pete495 · Feb 28, 2004

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.

WntrMute2 · Feb 28, 2004

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.

Oldsalt · Feb 29, 2004

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

WntrMute2 · Feb 29, 2004

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.

loisane · Mar 1, 2004

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

Oldsalt · Mar 1, 2004

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...

deepz · Mar 1, 2004

...Curative vs Supportive - Havent thought about it in that light ...

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

deepz