Jonathan Slonin, an anesthesiologist and past president of the Florida Society of Anesthesiologists, believes that lawmakers should not allow the administration of anesthesia without a physician in the room. Although he works with and respects Certified Registered Nurse Anesthetists (CRNAs), they are not physicians.
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They have years of training, but they are not trained in medical diagnosis and treatment, and while they are highly skilled and a vital part of the medical care team, they should never be the lead of that team.
While the American Association of Nurse Anesthetists are advocating for a proposed bill that would allow CRNA’s to practice without the supervision of a physician, some see this as a dangerous and costly move.
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...safety should be the primary goal and that is why physician-led care must remain the standard. If CRNAs were given complete independence to practice complex medicine, costly mistakes will happen. And when they do, we all pay for those mistakes through increased healthcare costs.
As I live in an area with a heavy kaiser presence, I wouldn't consider kaiser crnas a beacon for independent practice. I would expect crnas working there to be generally more sympathetic to physician oversight.
This statement demonstrates my point. The condescending attitude that is tacitly endorsed by the AANA. CRNA's that work in ACT settings are somehow less relevant and not practicing at the 'top of their license' whatever that means...There are Kaiser CRNA's that have been practicing quietly for years in that system who make plenty of 'independent' CRNA's look like amateurs. They choose to practice where they are because they choose to practice where they are. More skilled and knowledgeable does not necessarily flow from "Independent". As far as the AANA is concerned, there are two classes of CRNA and comments like the above just demonstrate that.
This statement demonstrates my point. The condescending attitude that is tacitly endorsed by the AANA. CRNA's that work in ACT settings are somehow less relevant and not practicing at the 'top of their license' whatever that means...There are Kaiser CRNA's that have been practicing quietly for years in that system who make plenty of 'independent' CRNA's look like amateurs. They choose to practice where they are because they choose to practice where they are. More skilled and knowledgeable does not necessarily flow from "Independent". As far as the AANA is concerned, there are two classes of CRNA and comments like the above just demonstrate that.
Youre twisting my words. People choose to work in ACTs for all sorts of reasons. It could be money. It could be location, schedule, or some other personal reason. Some people that want to do really big cases and ACTs are the only option.
However, ACT crnas tend to be a lot more accepting of supervision; using a survey from them to demonstrate that crnas think supervision is needed is silly. A better designed survey would include other practice models.
Every single point, besides our ICU requirement, is a broad generalization. Out of the 141 accredited CRNA programs in the US, there is no way anyone could make the claim that the training is as homogeneous as laid out above, nor the relative experience of the trainees. There superlative nurse anesthesia programs and there are superlative AA programs, but the difference is that AA's don't have the politics surrounding getting their blocks, lines, hearts etc...Non physician anesthesia training is a mixed bag and to say that every single nurse anesthesia training program adequately prepares their graduates for independent practice is just not true. I say this not to trash independent practice but to pressure the AANA/NBCRNA to make programs way less heterogeneous than they are or close them. You really have no idea what your getting with any given new grad CRNA until they show you, and that's not the exception, its the rule.
Advocating for improvements in the profession is always welcome. I have no doubt that minimum numbers will be raised soon given the averages I've seen from those graduating. There's always been a lag there.
What you're doing is choosing to selectively focus on the flaws of cnra training programs while ignoring those in medicine. There are tons of issues and inconsistencies with medical education: the emergence of the 3 yr med school, the pass/fail grading, physicians practicing despite failing boards. Plenty of new physicians show up quite weak to their first job. I can think of one guy our group got rid of this year for clinical issues; that was far from the first time.
Probably 1/3 of the crnas in our group have 2 years or less of experience. I have seen no clinical issues from them. No idea what you're talking about.
Youre twisting my words. People choose to work in ACTs for all sorts of reasons. Often it's related to location, schedule, or some other personal reason. Some people that want to do big cases and ACTs are the only option. Generally ACT crnas tend to be a lot more accepting of supervision; using a survey from them to demonstrate that crnas think supervision is needed is silly.
By that logic, using a survey from CRNA's in independent practice to demonstrate that supervision is not needed is silly too...Using surveys to determine policy is silly. Using anecdotes, broad generalizations and the absence of evidence fallacy to demonstrate the utility and safety of independent practice is silly. Not to beat a dead horse, but unless and until there is complete uniformity across all nurse anesthesia programs, no exceptions *or* the AANA/NBCRNA complex just straight up comes clean and recognizes that some training actually prepares for independent practice and some does not. If independent practice is so critical for the most authentic practice as a CRNA then the NBCRNA needs to just create a sub certification for that...CRNA(I) or something.
jfratian said:
Youre twisting my words. People choose to work in ACTs for all sorts of reasons. Often it's related to location, schedule, or some other personal reason. Some people that want to do big cases and ACTs are the only option. Generally ACT crnas tend to be a lot more accepting of supervision; using a survey from them to demonstrate that crnas think supervision is needed is silly.
jfratian said:
Advocating for improvements in the profession is always welcome. I have no doubt that minimum numbers will be raised soon given the averages I've seen from those graduating. There's always been a lag there.
What you're doing is choosing to selectively focus on the flaws of non physician training programs. There are tons of issues and inconsistencies with medical education: the emergence of the 3 yr med school, the pass/fail grading, physicians practicing despite failing boards. Plenty of new physicians show up quite. weak to their first job. I can think of one guy our group got rid of this year for clinical issues.
Probably 1/3 of the crnas in our group have 2 years or less of experience. I have seen zero clinical issues from them. No idea what you're talking about.
Working conditions aside, the worst anesthesia residency has better clinical preparation than the best nurse anesthesia program. Your narrow experience with a single group means nothing when broadly applied across the entire country. I'm going on 30 years as a CRNA and I say there is a difference. So who's right? And if experience is of no consequence, what is your beef with AA's?
Hundreds of independent practice CRNA groups hire new grads every day. They do just fine. Decades of data across millions of anesthetics support that. The number of independent practice is growing across the country...not shrinking. None of that would happen if it didn't work.
No AA has ever independently done an anesthetic so not sure how we'd even know.
Those neighbor kids must really be screwing up your lawn, huh?
Hundreds of independent practice CRNA groups hire new grads every day. They do just fine. Decades of data across millions of anesthetics support that. The number of independent practice is growing across the country...not shrinking. None of that would happen if it didn't work.
No AA has ever independently done an anesthetic so not sure how we'd even know.
They hire new grads that are as close to a sure thing as they can. But the field is limited and by no means universal...that's the point. Of all the SRNA's I've helped train since our group started 12 years ago, I'd say only 5 of them were OK to go independent, and most of those did. As to the last statement, we'd know the same way we know all those new grads 'do fine'. And if you really believe that there are not AA's that could practice independently, in the same setting as independent CRNA's, a meaningful number too, then you're just protecting an ideologic narrative, void of any intellectual honesty.
Is "based on my 30 yrs" going to be your answer to everything? From your comments, your baseline opinion of the nurse anesthesia residents seems pretty low. I suspect you're unlikely to get their best effort even if you really believe what you're saying.
Since we're being intellectually honest, certainly there are physicians who truly need supervision. Are you going to advocate for that?
Most crnas easily can be independent on day one because they generally train that way. An AA is never left alone in a room in school. They finish with 2 yrs of total healthcare experience. I suspect few AAs can practice independently, because that's what the TCU AA to CRNA bridge program graduates say about themselves.
Is "based on my 30 yrs" going to be your answer to everything? From your comments, your baseline opinion of the nurse anesthesia residents seems pretty low. I suspect you're unlikely to get their best effort even if you really believe what you're saying.
Since we're being intellectually honest, certainly there are physicians who truly need supervision. Are you going to advocate for that?
Most crnas easily can be independent on day one because they generally train that way. An AA is never left alone in a room in school. They finish with 2 yrs of total healthcare experience. I suspect few AAs can practice independently, because that's what the TCU AA to CRNA bridge program graduates say about themselves.
AA's can't practice independently because it's against the law, not because they lack the ability...your defense of the narrative is impressive...and the contradictions come fast and furious...most CRNA's...being left in a room alone is the metric for independent practice? I have no words...Question....If the choice existed, who would you rather do your anesthetic, JF, a new grad, new hire CRNA or a 5 year AA?
So what is it? Is experience worth something or isn't it? Gotta choose one or the other or the narrative unravels pretty quick....
Your personal experience isn't worth anything. You 10k cases in 30 yrs doesn't hold a candle to millions of safe anesthetics done by crnas without physician involvement.
AA's can't practice independently because it's against the law, not because they lack the ability...your defense of the narrative is impressive...and the contradictions come fast and furious...most CRNA's...being left in a room alone is the metric for independent practice? I have no words...Question....If the choice existed, who would you rather do your anesthetic, JF, a new grad, new hire CRNA or a 5 year AA?
We can straw man all day. Would you like a new physician or an experienced CRNA?
The probable lack of ability for AAs comes from a lack of training in independent models. And yes we can't study illegal things. We can and have compared physician care and it's interchangeable.
Yeah, I don't disagree. I was looking at a reddit thread and someone asked how much folk's ICU experience impacted their anesthesia job...Mine did tremendously, but I did liver transplant, tons of congenital cardiac repairs, tons of inner city morbidity and penetrating trauma....6 years worth. Less than 2 years in a neuro-ICU like several of my students? Not so much. We can't claim superior training and experience if all we do is point to an average. It needs to be a hard, non-negotiable line of at least 3 years. But that would limit the pool of applicants and that doesn't meet the AANA/NBCRNA production goals. Yeah, if it sounds like I'm pretty jaded it's because I am.
Asking for genuine input and out of curiosity, and based on anecdotes from nurses I've worked with who have prior ICU experience.
Why is ICU experience the benchmark? I've titrated drugs, I understand the balance between vasoactive drugs, I understand vents to an extent - enough of a base level to build on during CRNA training. What is it about the ICU that creates a more appropriate basis for CRNA training compared to ED and flight experience?
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This statement demonstrates my point. The condescending attitude that is tacitly endorsed by the AANA. CRNA's that work in ACT settings are somehow less relevant and not practicing at the 'top of their license' whatever that means...There are Kaiser CRNA's that have been practicing quietly for years in that system who make plenty of 'independent' CRNA's look like amateurs. They choose to practice where they are because they choose to practice where they are. More skilled and knowledgeable does not necessarily flow from "Independent". As far as the AANA is concerned, there are two classes of CRNA and comments like the above just demonstrate that.