CRNA scope of practice

WntrMute2 · Mar 16, 2004

So as to avoid the cliche'd "don't feed the troll" response, I'll try to be as open as possible. I'm starting med school in the fall and have (had?) considered MDA as a possible choice. But not a day goes by on the med forums where one does not see threads regarding the dwindling prospects of MDA's due to an increasing scope of practice for CRNA's.
Assuming the CRNA M&M rates are about the same as those for MDA's, in your view (or that of the AANA) is there ANY place at all for MDA's in the future of medical care? That is, is the ultimate goal (er, the ultimate position) of the AANA to expand the scope of practice of CRNA's to subsume the WHOLE of the scope of practice of MDA's - OR, does the AANA still see a role for MDA's, and therefor recognizes an upper limit to the scope of CRNA practice?
Plimpington

I'm not sure that an "upper limit" is recognized as such. All states at this point allow a practitioner to do what he or she was trained to do so there isn't a truelegal limit. I think the AANA recognizes that there are enough stools to go around and that mandy docs may not want to practice in the less desireable locals. Additionally, critical care medicine and pain management are areas not heavily explored by CRNAs as far as I know. If what you want is to manage a bunch of CRNAs then that area MAY be shrinking, I really don't know. However, I really do believe there is room for us all.

yoga crna · Mar 16, 2004

I think you are a little confused about scope of practice and the AANA. Nurse anesthetists have always have a full scope of practice related to the needs of surgical patients and the legal recognition of our practice. The AANA is the professional organization representing the profession. AANA is also very concerned about patient safety and education in anesthesia, but as such does not accredit schools or even certify nurse anesthetists. Those functions are performed by separate autonomous councils. CRNA practice is legal, recognized by legislatures, courts and insurance companies. Above all, CRNA practice is SAFE. If it wasn't we would not have the 100+ year history that we do.

As an aside, I recently had a conversation with a friend whose brother was going into MD anesthesiology. When he was in medical school, he realized that he didn't like taking care of patients, so decided to go into anesthesiology. I doubt if you can find many CRNAs that don't like patient care.

Please feel free to take me on regarding CRNA Scope of Practice, but leave

the AANA out of the discussion. Or else, I will be forced to present an in-depth and accurate assessment about the ASA and the economic forces that dominate their actions.

Yoga CRNA

Brenna's Dad · Mar 16, 2004

From a personal perspectice... myself and most of the CRNAs I practice with, do not mind and infact like, working in a team environment as long as we are allowed to practice anesthesia to the fullest.

However, I think all CRNAs (including the professional organization) are extremely supportive of independent practice and the need to ensure it's continuance.

That said, there are more than enough patients to go around. As a physician anesthetist, I cannot imagine you ever being out of work. What's important, is that you enjoy anesthesia. Unless you have been exposed to health care in your "prior life" it must be very difficult to predict what kind of medicine you might enjoy.

As Yoga said, I believe many medical students are confused regarding the past and present scope of nurse anesthesia practice.

loisane · Mar 16, 2004

Plimpington,

The responses here are completely accurate. It is a myth that CRNAs are trying to increase our scope of practice. It is more accurate to say that we are trying to maintain the scope of practice we have had for over a century.

IMHO, what you are describing is nothing but biased rhetoric, aimed to inflame medical students to rally around a political cause. The fact that you are motivated to get alternative views on the issues speaks well for you. Of course, we have our biases also. But you, as a critical thinker, can gather the info, analyze it, and decide for yourself.

At one time, all anesthesia was given without any physician participation (other than the physician performing the surgery/procedure). I believe the nurse anesthesia profession supports the continued existence of this practice model, as a potential choice in some situations.

Does that mean that we support this practice model for all anesthetics? No, I don't think so. I don't think anyone wants to go back to the days of zero MDAs.

But organized MDAs say that every anesthetic needs the participation of a MDA. We disagree with that.

You said "....does the AANA still see a role for MDA's, and therefor recognizes an upper limit to the scope of CRNA practice? " I would like for you to examine the assumptions in how you framed that question. My personal response is YES, I see a role for MDAs, and NO, I do not see an upper limit to the scope of CRNA practice. Can we not agree that it is possible to have both?

loisane crna

plimpington · Mar 16, 2004

I think you are a little confused about scope of practice and the AANA. Nurse anesthetists have always have a full scope of practice related to the needs of surgical patients and the legal recognition of our practice. The AANA is the professional organization representing the profession. AANA is also very concerned about patient safety and education in anesthesia, but as such does not accredit schools or even certify nurse anesthetists. Those functions are performed by separate autonomous councils. CRNA practice is legal, recognized by legislatures, courts and insurance companies. Above all, CRNA practice is SAFE. If it wasn't we would not have the 100+ year history that we do.
As an aside, I recently had a conversation with a friend whose brother was going into MD anesthesiology. When he was in medical school, he realized that he didn't like taking care of patients, so decided to go into anesthesiology. I doubt if you can find many CRNAs that don't like patient care.
Please feel free to take me on regarding CRNA Scope of Practice, but leave
the AANA out of the discussion. Or else, I will be forced to present an in-depth and accurate assessment about the ASA and the economic forces that dominate their actions.
Yoga CRNA

Whoa whoa,

One thing is clear though. Outside certain fellowship areas (pain, acute care, etc.) the scope of CRNA practice is concurrent with the whole scope of anesthesia practice as a whole. Therefore, the MDA (as far as I can gather) brings no special expertise to the practice of gas (below the sub-specialty level, anyway) and is, therefore, just another provider.

That being the case, I can't see ANY future for MDA's below the subspecialty level. Even in those situations where two providers are better than one, why would anybody pay the higher MDA salary when the CRNA is cheaper and provides not only the same quality of care, but also provides care throughout the entire scope of MDA practice.

What does the MDA bring to anesthesia (below the subspecialty level) other than an extra set of hands (for which, as you say, there are plenty of stools to go around)? If it's just an extra set of hands - I don't see a future in MDA.

I think it's clear from these posts that it is just an extra set of hands.

plimpington

plimpington · Mar 16, 2004

I think you are a little confused about scope of practice and the AANA. Nurse anesthetists have always have a full scope of practice related to the needs of surgical patients and the legal recognition of our practice. The AANA is the professional organization representing the profession. AANA is also very concerned about patient safety and education in anesthesia, but as such does not accredit schools or even certify nurse anesthetists. Those functions are performed by separate autonomous councils. CRNA practice is legal, recognized by legislatures, courts and insurance companies. Above all, CRNA practice is SAFE. If it wasn't we would not have the 100+ year history that we do.
As an aside, I recently had a conversation with a friend whose brother was going into MD anesthesiology. When he was in medical school, he realized that he didn't like taking care of patients, so decided to go into anesthesiology. I doubt if you can find many CRNAs that don't like patient care.
Please feel free to take me on regarding CRNA Scope of Practice, but leave
the AANA out of the discussion. Or else, I will be forced to present an in-depth and accurate assessment about the ASA and the economic forces that dominate their actions.
Yoga CRNA

I'm not sure why you are defending yourself against attacks I did not make. I'm not sure why I should leave the AANA out of the discussion. If I am interested in knowing what the professional goals of CRNA's are, doesn't it make sense to mention their professional association. They set policy, lobby, etc. Nor did I presume to refute any of the positions of the AANA. I merely wanted to know if the AANA saw any place for MDA's in the future of medicine. There's no question in my mind that the AANA is much more powerful than the ASA is.

Plimpington

plimpington · Mar 16, 2004

Plimpington,
You said "....does the AANA still see a role for MDA's, and therefor recognizes an upper limit to the scope of CRNA practice? " I would like for you to examine the assumptions in how you framed that question. My personal response is YES, I see a role for MDAs, and NO, I do not see an upper limit to the scope of CRNA practice. Can we not agree that it is possible to have both?
loisane crna

Honestly, I'm having trouble understanding why everybody seems so defensive on this subject. I'm not even a doctor yet. Just how much baggage do you think I could be bringing to these discussions? I don't think the question is in need of any rephrasing. There's no assumption surrounding it. I wanted to know if the AANA (or CRNA's as a group) see any place in the future of medicine for MDA's. You seem to suggest that they do (and then you bring up the ASA - what makes you think I agree with the ASA???).

AND WHAT makes you think that just because I've asked the question, I'm making some normative judgement about the scope of CRNA practice? I;m not. I have NO IDEA whether a CRNA is capable of subsuming the whole of the scope of practice of an MDA, nor do I assume they cannot. Likewise, I HAVE NO IDEA whether an MDA is overtrained (basically 8 years of training) in light of the fact that CRNA's can do all anesthesia with only 4 years of training, thus making the MDA inefficient and overpaid.

From my perspective, in any event, I can't understand your position on this issue. If the CRNA has equal expertise throughout the entire scope of practice as an MDA does, why should there be a place in anesthesia for an overpaid provider below the subspecialty level? Why would the free market for medical care ever "select" MDA's to administer anesthesia when they (1) don't have any extra expertise than CRNA's do, and (2) do not provide better care, and (3) cost about twice as much $$$? This makes no sense to me.

So, ask yourselves these questions and post here: (1) do MDA's do something that I do not do, and (2) is that extra something worth the extra cost of an MDA? If the answers to these questions are "no", I don't see a place for MDA's in healthcare below the subspecialty level, and therefor would probably do something else with my own career.

I'm asking for objective career advice - nothing more.

plimpington

yoga crna · Mar 16, 2004

First of all, you brought up the AANA without mentioning the ASA, so I feel comfortable defending the AANA's position in the discussion. If you want the official opinion of the AANA, please feel free to contact them. They are very reasonable and honest people.

As far as I am concerned, you answered your own question about the need for MD anesthesia. I think there will always be a place for both providers, because there is history for both of us. However, before long, the key element in practitioner usage will be economic. Medical care is a marketable commodity and the market will determine who provides care and at what price. By the time you finish medical school, you will probably be working for an HMO or the government and paid a salary. Of course, the same goes for CRNAs.

Also, I would like to defend our right to display some defensiveness and hostility. So many people offer negative comments about our profession without knowledge of what we do and the legality of our practice. I find it necessary to justify my practice every day and am comfortable doing it. Many of my patients are physicians and their families, including anesthesiologists. No excuses here, but always a willingness to take on any skeptics.

Yoga CRNA

loisane · Mar 16, 2004

Plimpington,

I am sorry if you perceive my response to you as defensive. I was trying to be very careful to present my opinion in a professional manner, for the purposes of discussion.

I used the term "assumption" within that context. It has no negative connotation. All arguments have underlying assumptions. The only error is to not recognize them. They need to be addressed, and identified.

You may not believe you have made a normative judgement, but my observation of your question framework suggested you may have. I don't know for a fact that you have, I only asked you to examine and decide for yourself.

Your statement/question is based on the assumption that IF there is a role for MDAs, then neccesarily there is an upper limit to the scope of CRNA practice. In order to give you my answer to your question, I have to share with you that I disagree with the assumption inherent within the question. I believe that there is a role for both MDAs and full scope of practice CRNAs within anesthesia. This opinion is based on my personal underlying philosophy.

Of course, philosophically is only one way to look at these issues. You mention the economic forces of a free market economy. And actually there are people within our community who make exactly the argument you quoted. If CRNAs have the exact same skill set as MDAs, why would the free market support the MDA role?

I guess it is an understatement to say these issues are complex. People more learned than you and I have made careers out of analyzing our health care system, how we got here, and where we should aim for the future.

Do MDAs do anything CRNAs do not do? No, CRNAs are educated to perform all anesthesia tasks (Now, I am talking abstract, globally. Obviously you can find individual MDAs who have abilities some individual CRNA does not. The reverse is also true).

All you want is career advice. Well, you have to look at all the angles, and then make your own judgement of what the future will most likely bring. We are all speculating-no different from picking a racehorse or a stock.

loisane crna

plimpington · Mar 16, 2004

First of all, you brought up the AANA without mentioning the ASA, so I feel comfortable defending the AANA's position in the discussion. If you want the official opinion of the AANA, please feel free to contact them. They are very reasonable and honest people.
As far as I am concerned, you answered your own question about the need for MD anesthesia. I think there will always be a place for both providers, because there is history for both of us. However, before long, the key element in practitioner usage will be economic. Medical care is a marketable commodity and the market will determine who provides care and at what price. By the time you finish medical school, you will probably be working for an HMO or the government and paid a salary. Of course, the same goes for CRNAs.
Also, I would like to defend our right to display some defensiveness and hostility. So many people offer negative comments about our profession without knowledge of what we do and the legality of our practice. I find it necessary to justify my practice every day and am comfortable doing it. Many of my patients are physicians and their families, including anesthesiologists. No excuses here, but always a willingness to take on any skeptics.
Yoga CRNA

Well, I'm not skeptic - in fact quite the opposite. I agree that economics will be the sole driver of anesthetic care in the future, and things being as they are, I don't see a place in medicine for MDA's.

I take with a grain of salt your assertion that you feel there is a place for MDA's in medicine in the future. Why? What do they do that you cannot?

Judd

Businessman · Mar 17, 2004

Judd,

If you love being a doctor, go for it! Knowing what will happen to a specific specialty 8-15 years from now is almost impossible, and one can offer only opinions and educated guesses, but there are many more factors that one cannot foresee. (see previous "bubbles" in other medical areas).

Your decision to attend med school should be driven primarily by the desire to cure - if that's the case, than you'll be happy regardless of what specialty you'll choose 4 years from now.