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.
Actually... many nurses have not taken chemistry or biology. And high school chem isn’t typically... deep. It’s.. high school.
Sometimes the zebras are what kills you. As an MD friend of mine said “if 75% of the time a symptom is a certain disease, the treatment may be what will kill him the another 5% of the time”
No kidding? I never knew that. Thanks for letting me know because I didn't know that before. Now I can enjoy being more enlightened . I often repeat "They're so cute when they're young" but that doesn't apply here.
I went to medschool for about a month and I can tell you that the didactic portion can be done fully online. In fact, a lot of medschools are actually making it optional to attend the didactic portion because a lot of students prefer it. IMO in medschool you need more time to study than anything else. The materials are not conceptually harder than the premed courses but it very dense. Hence the main difficulty is not about trying to understand the materials but its about being able to retain all that information in a short amount of time. Therefor time, in medschool, is very essential. This why a lot of students actually prefer watching the lecture online because they feel more efficient to study on their schedule.
I think that CRNA’s should be able to practice independently. Just like how how primary care physicians or other specialists should be able to practice independently. Everyone has limitations; physicians make referrals and asks for consultation all the time. In the case of CRNAs, most of the time they work with physicians and/or other medical providers. It can be with MDAs, Surgeons, Dentists, etc. At the end of the day, medical provision is a collaborative process and one profession cannot stand on its own.
Safety IS an issue, regardless of whether a physician anesthesiologist or a nurse anesthesiologist (CRNA) provides the care. It is better to base your opinions on fact and evidence rather than rhetoric and conjecture. There are no data suggesting that CRNAs provide suboptimal care. Any suspicion or reticence about the quality of care provided by independently practicing CRNAs can easily be assuaged by looking at two long-standing practice scenarios. 1). CRNAs possess full practice authorization in all military branches and serve as the main providers of anesthetic care to U.S. military troops in various locations worldwide. 2). CRNAs practice independently in 25 states and began doing so in 2001. Nurse anesthesiologists are some of the nation's most highly skilled and competent care providers due to their education, experience, training, and licensing requirements, along with over 160 years of history in professionalism and care. Certainly, if there were veracious evidence pointing toward patient safety issues or suboptimal care provided by independently practicing CRNAs, it would be abundantly clear by now. Nurse anesthesiology was nursing's very first nursing specialty. Physicians became interested in anesthesia as a specialty in 1937 and only then because of the allure of the money. Today's median income of a physician anesthesiologist is $430,000 - a price many rural community hospitals can ill afford.
Look to the evidence. The evidence supports the conclusion that CRNAs can and do provide safe, effective, and high-quality anesthesia care independently and positively impact the efficacy, efficiency, and access to quality healthcare.
Safety IS an issue, regardless of whether a physician anesthesiologist or a nurse anesthesiologist (CRNA) provides the care. It is better to base your opinions on fact and evidence rather than rhetoric and conjecture. There are no data suggesting that CRNAs provide suboptimal care. Any suspicion or reticence about the quality of care provided by independently practicing CRNAs can easily be assuaged by looking at two long-standing practice scenarios. 1). CRNAs possess full practice authorization in all military branches and serve as the main providers of anesthetic care to U.S. military troops in various locations worldwide. 2). CRNAs practice independently in 25 states and began doing so in 2001. Nurse anesthesiologists are some of the nation's most highly skilled and competent care providers due to their education, experience, training, and licensing requirements, along with over 160 years of history in professionalism and care. Certainly, if there were veracious evidence pointing toward patient safety issues or suboptimal care provided by independently practicing CRNAs, it would be abundantly clear by now. Nurse anesthesiology was nursing's very first nursing specialty. Physicians became interested in anesthesia as a specialty in 1937 and only then because of the allure of the money. Today's median income of a physician anesthesiologist is $430,000 - a price many rural community hospitals can ill afford.
Look to the evidence. The evidence supports the conclusion that CRNAs can and do provide safe, effective, and high-quality anesthesia care independently and positively impact the efficacy, efficiency, and access to quality healthcare.
Post-Covid, it's now up to 23 states plus D.C. Restrictions to practice were lifted during Covid and what happened? Nothing. I was fortunately already retired but my friends still working were sent to do intubations all over the hospital among all age groups. Now, I know that some people will say, that's just intubating, but they have no idea how many times it's not JUST intubating. All kinds of hairy scenarios arise. My worst was being called to intubate a patient on the floor in pre-op. There was something off about her airway that made me leery. It turned out that she was post radical neck dissection but not like the old timey ones with hair on her tongue. It was the best plastic repair I had ever seen for that kind of surgery. You can kill a patient like that if you even make a clumsy attempt to insert the blade. In the end, I had to bag her for four hours waiting for the thoracic surgeon (hers) come from Manhattan across the river. It doesn't make any difference what the initials of the person attempting to evaluate an airway on the floor. It's just a matter of being thorough and cautious under high stress conditions. My hands were never the same:(
Probably the most telling stats in this argument come from actuaries. No bias all math. CRNAs practicing in restrictive care team models with heavy physician supervision pay the exact same malpractice premiums as those who practice independently. Why exactly would that be if supervision was integral to patient safety? This actuarial data is freely available. As is the data in the numerous studies cited earlier in this discussion.
For example, my premiums go up if I decide to move to a more litigious zip code. But go from heavy physician supervision to independent practice...no change. My neighbor (another CRNA who works in a heavily supervised community hospital in wealthy area) and myself (an independent CRNA at a safety net hospital in a poor area) pay the same thing. We've been practicing the same number of years and neither have claims.
Probably the most telling stats in this argument come from actuaries. No bias all math. CRNAs practicing in restrictive care team models with heavy physician supervision pay the exact same malpractice premiums as those who practice independently. Why exactly would that be if supervision was integral to patient safety? This actuarial data is freely available. As is the data in the numerous studies cited earlier in this discussion.
For example, my premiums go up if I decide to move to a more litigious zip code. But go from heavy physician supervision to independent practice...no change. My neighbor (another CRNA who works in a heavily supervised community hospital in wealthy area) and myself (an independent CRNA at a safety net hospital in a poor area) pay the same thing. We've been practicing the same number of years and neither have claims.
Playing devils advocate here...how do you answer the objection that care teams most usually operate in higher complexity, tertiary settings so it's not apples to apples?
Playing devils advocate here...how do you answer the objection that care teams most usually operate in higher complexity, tertiary settings so it's not apples to apples?
That was my first thought. I've worked in a small place indepently and a large teaching facility where they must have MD's in house for ICU, OB and general OR coverage.
I suspect major university teaching hospitals will always be physician dominant, so we'll probably never know the answer to that question.
At an anecdotal level, I practice in an a part of the country where all physician groups are routinely replaced by all-CRNA or mostly-all CRNA groups. (We don't exclude them by the way, they often just don't want to work with us even despite the 60% pay premium.) There's been no raft of safety issues following these changeovers at dozens of mid-size hospitals and ASCs. The ASA would have been all over it if there were.
On a broader level, the extent of supervision in most places is laughable: Essentially a 30 sec convo with the patient and an EHR note. I'm not sure how any reasonable person can credit it with improved safety. Even within true care teams, the famous Dexter/Epstein 2012 study found the 7 TEFRA guidelines are met 10% of the time in 4:1 teams.
ArmyRntoMD, BSN, RN
314 Posts
Actually... many nurses have not taken chemistry or biology. And high school chem isn’t typically... deep. It’s.. high school.
Sometimes the zebras are what kills you. As an MD friend of mine said “if 75% of the time a symptom is a certain disease, the treatment may be what will kill him the another 5% of the time”
Differential diagnosis is key.