What do you think (if anything) MDA's will do...

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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 with this of course but politicians should keep this in mind when considering their input on issues). It doesn't matter if you are talking about government workers, teachers, Dr's or CRNA's. One need only to witness some of the caustic things that were put out by the AMA during the debate concerning "opt out" provisions for Medicare of direct physician supervision of CRNA's.

Without regard to whether or not this is actually THE CASE MDA's PERCEIVE CRNA's as something of a threat. My question is what will their LONG TERM strategy be for dealing with this threat. Possibilities that I can think of might include:

I. Working to increase the standards of education for CRNA's. Perhaps, getting CRNA schools to introduce an additional semester or two of courses like gross anatomy, and or pathophysiology. This would be an interesting approach since it would probably garner the support of many CRNA's who would benefit (at least in the short term) by the even greater shortage it would facilitate. The decrease in graduating CRNA's might encourage the common use of CRNA's to "go out of common practice" in many locales.

II. Another route they might follow would be to seek regulation AT THE STATE LEVEL which would make it more difficult for CRNA's to effectively practice. Perhaps mandating A CERTAIN TYPE of liability insurence (not availible from CRNA associations) that would make it less viable for CRNA's to practice.

III. Yet another tactic would be to fight the EXPANSION of existing CRNA educational facilities with a result similar to #I above in the long term.

My question is are CRNA organizations anticipating such action and even more importantly what are they doing to fight back?

roland,

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:)

1. 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.

very valid points...

Tenesma

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 schools 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.

Kevin McHugh

that "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.

Roland:

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 "

"study"

"reseach"

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.....

cheers :D

however 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.

""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.

S

Kevin,

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?)...

"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!

that 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?

The AANA, both state and national, and the AANA PAC.

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