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.
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?
The accreditation standards read "minmum 1 year of critical care experience." Some programs will take ER experience on a case by case basis if they consider it critical care. In my graduating class we had one ER nurse; her level 1 ER routinely had vented pts on drips. You can call the programs you're interested in and see if they'd accept it.
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?
Learning the culture of critical care, the 'chain of command', savy as to how to get things done, ie, maybe interacting with lab, BB, pharmacy etc...it's more intense and sustained in a CC area than the ER...monkey skills are really important, but they can be picked up in pretty short order. There is a certain situational awareness that you develop working in CC that is directly applicable in the operating room and that has nothing to do with the 'at task' aspects. That's my take. And it's why the minimum of one year is a joke.
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.
I'd pick an experienced CRNA, of course. Just like you would choose the experienced AA but won't say. And independent models don't mean a thing if a meaningful number of the cases are not 3's and 4's coming for more than hips and knees. There are independent groups like that but I wonder how many students go through them. Where I am, the indy shops move the complex patients out as often as they can and they're happy to do it. And to be clear, a significant part of my career has been in indy/CRNA only practice (not now). I endorse it. My beef is the claim by the powers that *any* new grad CRNA can walk into *any* independent setting and function safely. Some can in *some* settings, of course they can and they do. Again, the disingenuous claim that it has been definitively demonstrated is not true and they know it can never be because RCT's would be impossible to design without bias or ethical considerations.
This is and ideologic position that is defended at the cost of a voluntary suspension of intellect by some really smart people. I have nothing to lose by pointing out the short comings but if the AANA/NBCRNA are really serious, they'll stop provoking the very groups SRNA's depend on for their most critical training experiences (hint...not shoulder blocks in BFE) and make anesthesia training across the board to the level of USAGPAN or it's equivalent if there is one. The tit for tat politics with the ASA is degrading nurse anesthesia training.
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.
Right..so we're back to the thinly veiled contempt of the AANA for CRNA's that don't practice in indy settings...The sneering doesn't go unnoticed and I have to wonder if the rhetoric and dues paying membership are inversely related. In my small group the majority have indy side gigs and no one is an AANA member.
Right..so we're back to the thinly veiled contempt of the AANA for CRNA's that don't practice in indy settings...The sneering doesn't go unnoticed and I have to wonder if the rhetoric and dues paying membership are inversely related. In my small group the majority have indy side gigs and no one is an AANA member.
You're not an AANA member...I'm shocked.
No contempt or sneering...just varying levels of evidence. The individual experiences of any one person aren't enough to make system level policy decisions. CRNA indie practice is widespread, has been going on for decades, is growing, and is widely supported by the available literature. Your personal experiences in your possie of mean girls not withstanding.
I'd pick an experienced CRNA, of course. Just like you would choose the experienced AA but won't say. And independent models don't mean a thing if a meaningful number of the cases are not 3's and 4's coming for more than hips and knees. There are independent groups like that but I wonder how many students go through them. Where I am, the indy shops move the complex patients out as often as they can and they're happy to do it. And to be clear, a significant part of my career has been in indy/CRNA only practice (not now). I endorse it. My beef is the claim by the powers that *any* new grad CRNA can walk into *any* independent setting and function safely. Some can in *some* settings, of course they can and they do. Again, the disingenuous claim that it has been definitively demonstrated is not true and they know it can never be because RCT's would be impossible to design without bias or ethical considerations.
This is and ideologic position that is defended at the cost of a voluntary suspension of intellect by some really smart people. I have nothing to lose by pointing out the short comings but if the AANA/NBCRNA are really serious, they'll stop provoking the very groups SRNA's depend on for their most critical training experiences (hint...not shoulder blocks in BFE) and make anesthesia training across the board to the level of USAGPAN or it's equivalent if there is one. The tit for tat politics with the ASA is degrading nurse anesthesia training.
The available literature, though flawed, shows indie practice for CRNAs is broadly safe; what's out there is far more compelling than any one person's experience. Legislatures and hospital leadership increasingly agree. Are there weak individuals who shouldn't do so? Of course. You could say the same about a handful of physicians who need a lot of extra help after residency; there is plenty of room for them to hide in a big academic practice. You choose to fixate on CRNA flaws based on personal anecdotes; there are plenty of physician anecdotes to go around.
You choose to not pay dues, ride our advocacy coattails, and bemoan it as 'pointless tit for tat politics.' However, you happily take the increased compensation and job opportunities they bring. I'm thankful the vast majority of our profession disagrees with you.
Learning the culture of critical care, the 'chain of command', savy as to how to get things done, ie, maybe interacting with lab, BB, pharmacy etc...it's more intense and sustained in a CC area than the ER...monkey skills are really important, but they can be picked up in pretty short order. There is a certain situational awareness that you develop working in CC that is directly applicable in the operating room and that has nothing to do with the 'at task' aspects. That's my take. And it's why the minimum of one year is a joke.
With the caveat that I have never worked ICU, I'd argue that we do those very same things in the ED every day, amplified by the fact that we are generally 4-5:1 and must learn to rapidly prioritize our care. Additionally, our patients are regularly unstable but more important they're undifferentiated. For the most part, ICU patients have a definitive diagnosis which at least gives some direction.
Anyway, this is just internet chatter, I know the governing bodies aren't reading this and thinking "oh well we should probably allow ED experience because of that random dude on the internet".
Again encourage you to contact programs you're interested in and see what they say. It's a grey area. This is why the COA requires 'critcal care' and not 'ICU' experience. Some ERs give great experience with critically I'll patients. Some are closer to urgent cares. I wish you luck.
Again encourage you to contact programs you're interested in and see what they say. It's a grey area. This is why the COA requires 'critcal care' and not 'ICU' experience. Some ERs give great experience with critically I'll patients. Some are closer to urgent cares. I wish you luck.
2 out of 3 programs in my area specifically exclude ED, the third does not. I have another year before I can apply due to other obligations, I'll start investigating at that point
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.
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?
Offlabel, I graduated I. 1984 when CRNA school didn't have online classes, we had consistent instructors who worked for the program, did an ICU rotation,worked 24 hr., et al. My school only accepted 10 and I bet yours was close. NowI see students being supervises by MDA'a who are only interested on molding students to their tastes, then the students move onto another location where, once again, nobody knows if they are growing or not, and the class sizes are huge. We are cranking out hot dogs. I'm alarmed when students can pick their own cases to work with kids who graduated the year before. I was working alone after 2 weeks. You just can't do that anymore with more whimsical approach that we have now. You woukd be hard pressed to see a program that even has an requirement for organic Chem or physics anymore. J know the University of Iowa does but that's about it.
We should always be on the look out for alarming trends in training and education. And certainly should address accordingly where appropriate. I think its a bit of a stretch to imply new providers are incompetent.
I would argue worrying trends exist across all higher ED. There's rampant grade inflation or nearly everything is pass/fail. People are pushed through training due to fear of lawsuits. This is coming from surgeons I work with. It's not unique to crnas.
Offlabel, I graduated I. 1984 when CRNA school didn't have online classes, we had consistent instructors who worked for the program, did an ICU rotation,worked 24 hr., et al. My school only accepted 10 and I bet yours was close. NowI see students being supervises by MDA'a who are only interested on molding students to their tastes, then the students move onto another location where, once again, nobody knows if they are growing or not, and the class sizes are huge. We are cranking out hot dogs. I'm alarmed when students can pick their own cases to work with kids who graduated the year before. I was working alone after 2 weeks. You just can't do that anymore with more whimsical approach that we have now. You woukd be hard pressed to see a program that even has an requirement for organic Chem or physics anymore. J know the University of Iowa does but that's about it.
Very similar experience...both then and now....the irony is that my starting salary was 62,500 and now, its what? Averaging 200-250K? Way more if new grads drop right into locums. Our group can't maintain steady call positions because only a few folks are willing to take call, weekends, holidays. You better believe premiums are attached to those jobs and its not because of AANA "advocacy". It's purely market forces. That also means that the learning curve is pretty steep, so there are more than a few blood patches when someone new comes along, if you get the drift. As reimbursement falls, relying on hospital stipends increases as do incentives to work that were completely unheard of 30 years ago. Yeah, I'm riding the gravy train, because so many people don't want the extra money. And if we're not careful, we'll price ourselves right out of existence in some places.
jfratian, DNP, RN, CRNA
1,665 Posts
The accreditation standards read "minmum 1 year of critical care experience." Some programs will take ER experience on a case by case basis if they consider it critical care. In my graduating class we had one ER nurse; her level 1 ER routinely had vented pts on drips. You can call the programs you're interested in and see if they'd accept it.