CRNA Vs. MD

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Hello everyone, just found this site so this is my first post.

Currently I am an undergrad working on acceptance to medical school. I'm not going to lie though, a majority of the motivation is the money. I just discovered CRNA's though and they make a lot of money with little debt doing roughly the same thing I wanted to do in the first place. I have a few questions I hope someone can help me out with here:

1) On a day-to-day basis, what would a CRNA end up doing? This can be broad, I just want to get an idea of if it's just put patients to sleep and wake them up or more.

2) How long would it take me to get a CRNA. Currently I am a sophomore in Psychology (finished all physics, bio, chem, math).

Thanks!

Were are these rules mda's are required to over see crna? It's the darn dr who are pushing these these made up political rules but by law we dont need them and they dont like it period.

42CFR485.639 ©(2) In those cases in which a CRNA administers the anesthesia, the anesthetist must be under the supervision of the operating practitioner except as provided in paragraph (e) of this section. An anesthesiologist's assistant who administers anesthesia must be under the supervision of an anesthesiologist.

(e) Standard: State exemption. (1) A CAH may be exempted from the requirement for physician supervision of CRNAs as described in paragraph ©(2) of this section, if the State in which the CAH is located submits a letter to CMS signed by the Governor, following consultation with the State's Boards of Medicine and Nursing, requesting exemption from physician supervision for CRNAs. The letter from the Governor must attest that he or she has consulted with the State Boards of Medicine and Nursing about issues related to access to and the quality of anesthesia services in the State and has concluded that it is in the best interests of the State's citizens to opt-out of the current physician supervision requirement, and that the opt-out is consistent with State law.

Once again: these are CMS BILLING RULES not laws. And the 'supervision' so mentioned is not supervision as conventionally understood--it is a request for anesthesia services, with the 'supervising' physician neither expected to be knowledgeable regarding the anesthesia provided, nor legally liable for its outcome. In no state in the US is a CRNA legally required to be supervised by a physician who advises, proscribes or approves of the anesthetic plan.

The Indiana Hospital Licensure Rules ("Rules") address the provision of

anesthesia services in a hospital. 410 IAC 15-1.6-1 ( A LAW IN OUR STATE) states as follows:

Anesthesia shall be administered by those privileged by the medical

staff who are:

i. An anesthesiologist;

ii. A qualified physician with appropriate training, experience

and privileges;

iii. A dentist, oral surgeon or podiatrist who is qualified to

administer anesthesia under state law;

iv. A CRNA who is under the direction of the operating

practitioner or of a qualified physician who is

immediately available if needed. (Emphasis added).

The Rules make it clear that a CRNA may practice either under the

direction of the "operating practitioner" or, alternatively, under the

direction of a qualified physician who is immediately available

The Indiana Hospital Licensure Rules ("Rules") address the provision of

anesthesia services in a hospital. 410 IAC 15-1.6-1 ( A LAW IN OUR STATE) states as follows:

Anesthesia shall be administered by those privileged by the medical

staff who are:

i. An anesthesiologist;

ii. A qualified physician with appropriate training, experience

and privileges;

iii. A dentist, oral surgeon or podiatrist who is qualified to

administer anesthesia under state law;

iv. A CRNA who is under the direction of the operating

practitioner or of a qualified physician who is

immediately available if needed. (Emphasis added).

The Rules make it clear that a CRNA may practice either under the

direction of the "operating practitioner" or, alternatively, under the

direction of a qualified physician who is immediately available

This state law still SAYS that anesthesia may be provided by "a CRNA who is UNDER THE DIRECTION of the operating practitioner or (UNDER THE DIRECTION) of a qualified physician who is immediately available if needed." Sorry for being so dense, but the phrase "under the direction" could be construed as "under the supervision" couldn't it? If I am "under the direction or supervision" of somebody higher up in the food chain than I am, it means they tell me what they want and I make it happen. I have some leeway in complying with their wishes, but I can't unilaterally decide that I am going to do something other than what they want. There is usually somebody nearby that makes sure that what I'm doing is satisfactory, and who can give me a hand if something goes wrong. I am not saying that the "director/supervisor Dr." is breathing down the neck of the CRNA, any more than my supervisor monitors every single thing *I* do.

The language of either the federal regulation which I quote elsewhere or the state regulation quoted here by Paindoc, doesn't really lend itself to the interpretation that CRNA's are autonomous and beyond the purview of a Doctor... and that this is some kind of "billing" law. I don't really see anything in this law as it is written that specifies that this is only to be used for billing purposes. Maybe there is a difference in medical parlance as opposed to "the rest of us." That being said, I am choosing to read the law as written in the strictest interpretation, that it means EXACTLY what it says; that a CRNA, unless otherwise exempted, MUST be (federal) or IS (state) under the direction/supervision of a physician, whether an operating practitioner (MD of some kind, surgeon, OBGYN etc.) or another physician (MD) who is immediately available. What I quoted is a federal regulation pertaining to CRNA supervision. It is also the law in Indiana where Paindoc got the legislation pertaining to CRNA direction that appears here. I hope we are not going to argue what "is" is...:)

Specializes in CRNA.
That being said, I am choosing to read the law as written in the strictest interpretation, that it means EXACTLY what it says; that a CRNA, unless otherwise exempted, MUST be (federal) or IS (state) under the direction/supervision of a physician, whether an operating practitioner (MD of some kind, surgeon, OBGYN etc.) or another physician (MD) who is immediately available. What I quoted is a federal regulation pertaining to CRNA supervision. It is also the law in Indiana where Paindoc got the legislation pertaining to CRNA direction that appears here. I hope we are not going to argue what "is" is...:)

CRNAs in 20 states are exempt from the federal Medicare billing regulations for superivision, that's a significant number of CRNAs. Indiana has the most restrictive state law related to CRNA practice, and so you can say that the dentist is superivising the CRNA in the state of Indiana, but this is far from supporting the statement that CRNAs are always supervised by a physician. That's the issue at discussion here, not if CRNAs are supervised by physicians, but rather it is: Must CRNAs always be supervised by a physician? and the answer is No, CRNAs are not always required to be supervised by a physician. A more nuanced answer is: In many cases the CRNA will have a supervising physician, but that physician does not direct the administration of the anesthetic, and the CRNA is 100% liable for the anesthetic.

I don't want to argue what "is" is, but I will argue what "always" is.

Specializes in Anesthesia.
This state law still SAYS that anesthesia may be provided by "a CRNA who is UNDER THE DIRECTION of the operating practitioner or (UNDER THE DIRECTION) of a qualified physician who is immediately available if needed." Sorry for being so dense, but the phrase "under the direction" could be construed as "under the supervision" couldn't it? If I am "under the direction or supervision" of somebody higher up in the food chain than I am, it means they tell me what they want and I make it happen. I have some leeway in complying with their wishes, but I can't unilaterally decide that I am going to do something other than what they want. There is usually somebody nearby that makes sure that what I'm doing is satisfactory, and who can give me a hand if something goes wrong. I am not saying that the "director/supervisor Dr." is breathing down the neck of the CRNA, any more than my supervisor monitors every single thing *I* do.

The language of either the federal regulation which I quote elsewhere or the state regulation quoted here by Paindoc, doesn't really lend itself to the interpretation that CRNA's are autonomous and beyond the purview of a Doctor... and that this is some kind of "billing" law. I don't really see anything in this law as it is written that specifies that this is only to be used for billing purposes. Maybe there is a difference in medical parlance as opposed to "the rest of us." That being said, I am choosing to read the law as written in the strictest interpretation, that it means EXACTLY what it says; that a CRNA, unless otherwise exempted, MUST be (federal) or IS (state) under the direction/supervision of a physician, whether an operating practitioner (MD of some kind, surgeon, OBGYN etc.) or another physician (MD) who is immediately available. What I quoted is a federal regulation pertaining to CRNA supervision. It is also the law in Indiana where Paindoc got the legislation pertaining to CRNA direction that appears here. I hope we are not going to argue what "is" is...:)

Again it is one thing debating paindoc who actually knows what he is talking, but you just don't have the background to even get into this debate that is older than you and I put together. You also seem to have a personal grudge against anesthesia providers in general as evidenced by your previous posts on versed and sedation.

Neveragain:

"In theory the patient is allowed to have some say over sedation drugs or anything else for that matter. In practice it's not true. My nurse never said a word even though she knew that I had declined the drugs and had not signed an informed consent for same. I think she was intimidated (?) by the CRNA and the Doctor."

1. The CMS regulation to qualify for billing supervision that you quoted has recently changed. CRNAs can provide and bill for MAC and epidurals independently even in non opt out states.

2. Being "under the direction" of someone that is not an MDA or CRNA to provide anesthesia is a joke, and if it makes you feel better that a Dentist, podiatrist, or non anesthesiologist physician signs a piece of paper requesting anesthesia services or more likely in rural hospitals it is probably just part of their formal protocol that CRNAs can provide anesthesia services for appropriately credentialed providers then that is great. There is big difference between meeting criteria for billing/state scope of practice issues and actually having someone tell you how to administer your anesthetic.

3. These issues of scope of practice/opt-out are all about politics money and control. Sometimes the ASA/AMA wins and sometimes the AANA wins. It has nothing to do with public safety or anything else, because CRNAs have been shown over and over again to be as safe or safer than any other anesthesia provider there is.

4. GasWork.com - Reference #118218 This sure looks like independent practice in Indiana, unless you think all the operating providers there are really doing anything more than signing a piece of paper or following a formal protocol when requesting anesthesia services from a CRNA.

Specializes in Anesthesia.

The Indiana Hospital Licensure Rules ("Rules") address the provision of

anesthesia services in a hospital. 410 IAC 15-1.6-1 ( A LAW IN OUR STATE) states as follows:

Anesthesia shall be administered by those privileged by the medical

staff who are:

i. An anesthesiologist;

ii. A qualified physician with appropriate training, experience

and privileges;

iii. A dentist, oral surgeon or podiatrist who is qualified to

administer anesthesia under state law;

iv. A CRNA who is under the direction of the operating

practitioner or of a qualified physician who is

immediately available if needed. (Emphasis added).

The Rules make it clear that a CRNA may practice either under the

direction of the "operating practitioner" or, alternatively, under the

direction of a qualified physician who is immediately available

What exactly does a non anesthesiologist in Indiana have to do to become qualified?

Anesthesiologist: 4 years medical school, 4 years of residency. 8 years to become a MD.

CRNA: 2 years BSN, 3 years getting required experience, 2.5 years school. 7.5 years to become a CRNA.

I'm not seeing much of a difference here? And the CRNA plan is assuming you can actually get 1 year full-time ICU experience that quickly out of school. On top of that, some schools require CCRN which takes longer. Since the OP has already been gearing the undergrad towards med school, I'd vote that med school is faster at this point in time.

ForeverLaur, you forget that medical school also requires a bachelor's degree so that's 4 more years for an MD (plus any fellowships, etc.) CRNA is definitely the shorter route.

To quote, the "relative paucity of significant homeostasis imbalance induced by modern medications"?? It's pretty obvious that you've spent any time behind the curtain with a CRNA to know the potency of the drugs they are passing and how delicate the balance truly is of homeostasis. I admit, the CNRA will tell you, 95% percent of the job can be boring, but the other 5% sheer terror, when things go south. That is where the high salary comes from...the ability to stabilize a potentially fatal situation and lord knows I don't want anyone six months out of high school handling the drugs and my life when I'm under the scalpel.

I practice in Indiana and it is true that I am "under the direction" but this consists of would you perform an anesthetic, now the surgeon can state what they want SAB general etc, etc. But that does mean I have to do it, no I have told the surgeons no more then once. In the end the CRNA devises the plan and executes it... so much for "direction"

I was factoring in that the OP already had a bachelor's degree so another one would not need to be obtained to go to medical school. A BSN would need to be acquired for CRNA. For a normal individual without a college degree, the MD/DO path would be 4 years longer than I posted.

So, a CRNA in Indiana practicing independently without deference to the directing physician is violating State law. And freely admits it. Hmmmmm.....

With respect to "5% sheer terror" giving anesthetics, that high of a percentage would be due to inexperience of the provider rendering the anesthetic. Even though I did cardiac and liver transplantation anesthesia in the past which are by far the most severe challenges for anesthesia, I did not experience 5% sheer terror even with those cases. Anesthesia is not just boring, it is extremely overpaid for what services are actually rendered. I could take a person off the street with absolutely no medical training, and within a few months have them giving a smooth anesthetic that would rival what MDAs or CRNAs could give. Emergency situations? That is where MDAs or CRNAs should be used to bail out the lower level providers who would be capable of handling 99% of cases without the continuous presence of a CRNA or MDA.

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