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.
At an anecdotal level, I practice in an a part of the country where all physician groups are routinely replaced by all-CRNA or nearly-all CRNA groups. (We don't exclude them by the way, they often just don't want to work with us.) 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.
I think that is correct for most of the OR but a CRNA is never going to be in charge of an ICU as our anesthesiologists do. We are not qualified to do that. Tefra qualifications are a rip off but I'm old enough to remember working before TEFRA and why in even came about. A lawsuit in Minneapolis by CRNA's against the MDA's forced the feds to create TEFRA. That came to bite us in the ***. We all are aware that it makes us all non-compliant since you couldn't run an OR by bending to it's stipulations. It's strictly a billing requirement to make sure that the MDA's get out if their street clothes at work.
Definitely not implying physician anesthesiologists can be replaced by us. Theres plenty of work to go around. However, I would point out that most generalist physician anesthesiologists can't do ICU either; those that do often have additional training beyond their anesthesia residency. Physician anesthesia groups don't seem to be eagerly beating down the doors for poor paying ICU intensivist coverage either.
Definitely not implying physician anesthesiologists can be replaced by us. Theres plenty of work to go around. However, I would point out that most generalist physician anesthesiologists can't do ICU either; those that do often have additional training beyond their anesthesia residency. Physician anesthesia groups don't seem to be eagerly beating down the doors for poor paying ICU intensivist coverage either.
The ICU can generate money for the corporation when it is managed by an anesthesiologist. What specialty is more suited to manage the ICU?
The ICU can generate money for the corporation when it is managed by an anesthesiologist. What specialty is more suited to manage the ICU?
Now we're getting into the weeds...the fight in CC isn't who 'gets' to do it, rather who will do it because 'I don't want to'....CRNA's do L and D all day, every day by ourselves. Appendices, gall bladders, perf'ED viscus', even pediatric trauma dumped on the back door...that's not what we're talking about...it's the known acreta's, the ascending dissections, the ruptured AAA's, the septic 6 month mom...that's where anesthesiologists and CRNA's as a team shine. And these are not university systems...they're free standing 350 bed facilities in between BFE and NYC...and there are tons of them....I call them 'helicopter cases...."
Not sure who should manage ICU, but in practice it seems to be pulmonology, the acute care surgeon, the CT surgeon, or neurosurgeon depending on the case. I rarely see anesthesia managing ICU apart from a rare central line here or an intubation there.
I'm all for teamwork, but I reject the implicit premise in the broader medical community that the only options for anesthesia staffing are either 1 CRNA alone in the woods or a hierarchical ACT with a physician controlling 4 subordinate CRNAs. Our group handles all sorts of emergencies with different mixes of providers. Sometimes it's two CRNAs. Sometimes it's a CRNA and a physician anesthesiologist. It's about the skillset of the individuals involved and not arbitrary practice restrictions based on titles.
Not sure who should manage ICU, but in practice it seems to be pulmonology, the acute care surgeon, the CT surgeon, or neurosurgeon depending on the case. I rarely see anesthesia managing ICU apart from a rare central line here or an intubation there.
I'm all for teamwork, but I reject the implicit premise in the broader medical community that the only options for anesthesia staffing are either 1 CRNA alone in the woods or a hierarchical ACT with a physician controlling 4 subordinate CRNAs. Our group handles all sorts of emergencies with different mixes of providers. Sometimes it's two CRNAs. Sometimes it's a CRNA and a physician anesthesiologist. It's about the skillset of the individuals involved and not arbitrary practice restrictions based on titles.
I worked for a group that paid the hospital 7 figures to be in charge of the OR and the ICU's. We all know that no one is "controlling" 4 CRNA's at once. Now I'm confused as to what your actual point is now:) We have autonomy in my state post-Covid and we have known since it was started, that Tefra was a knee-jerk reaction and not a solution to any problem except getting MDA's into the rooms when they are sending the bills.
Now we're getting into the weeds...the fight in CC isn't who 'gets' to do it, rather who will do it because 'I don't want to'....CRNA's do L and D all day, every day by ourselves. Appendices, gall bladders, perf'ED viscus', even pediatric trauma dumped on the back door...that's not what we're talking about...it's the known acreta's, the ascending dissections, the ruptured AAA's, the septic 6 month mom...that's where anesthesiologists and CRNA's as a team shine. And these are not university systems...they're free standing 350 bed facilities in between BFE and NYC...and there are tons of them....I call them 'helicopter cases...."
I'm not clear on what your point is. Yes, there are cases everywhere that require two people from anesthesia, not just big teaching centers. When a single stab wound goes through the aorta AND the vena cava, we don't wait until they send them out:) That one was effectively dead when he arrived in the OR but a crazy young ER doc dragged him down to the OR anyway. A waste of 10 units of blood which I had to mostly give before an anesthesiologist arrived. I was the only person in-house that night. Sometimes we just get lucky.
I worked for a group that paid the hospital 7 figures to be in charge of the OR and the ICU's. We all know that no one is "controlling" 4 CRNA's at once. Now I'm confused as to what your actual point is now:) We have autonomy in my state post-Covid and we have known since it was started, that Tefra was a knee-jerk reaction and not a solution to any problem except getting MDA's into the rooms when they are sending the bills.
While that sounds nice, 7 figures isn't much when you probably need 4 or 5 FTEs worth of physician anesthesiologists each making 600k/yr to cover one person in one ICU 24/7; imagine multiple ICUs with multiple people needed at a time. Pulmonologists are much cheaper. That's why regular anesthesia ICU coverage is very rare outside a major teaching hospital. ICU coverage is not a critical competency that the CRNA profession lacking when bidding on contracts. I don't see this as a meaningful differentiator between physician anesthesiologists and CRNAs.
My only point with all the premise of this thread is a wrong. CRNAs don't need supervision. Where it exists in current practice it's lacking and doesn't contribute to patient safety in any meaningful way. My current day to day practice is proof of that.
I believe there's an IM subspecialty for critical care docs, pretty much specifically trained for the ICU..
Doesn't mean that they are required. My group paid 1 million dollars to the hospital to get the position. IMHO, that's corrupt but at the time, they were the best trained people for the job.
While that sounds nice, 7 figures isn't much when you probably need 4 or 5 FTEs worth of physician anesthesiologists each making 600k/yr to cover one person in one ICU 24/7; imagine multiple ICUs with multiple people needed at a time. Pulmonologists are much cheaper. That's why regular anesthesia ICU coverage is very rare outside a major teaching hospital. ICU coverage is not a critical competency that the CRNA profession lacking when bidding on contracts. I don't see this as a meaningful differentiator between physician anesthesiologists and CRNAs.
My only point with all the premise of this thread is a wrong. CRNAs don't need supervision. Where it exists in current practice it's lacking and doesn't contribute to patient safety in any meaningful way. My current day to day practice is proof of that.
Many years ago (back in the 80's?), a study was done by Kaiser with anesthesiologists and CRNA and they shockingly:) agreed that 90% of cases don't need supervision at all. That struck home with me. So, except for the 10% subspecialty cases, I agree with you.
Many years ago (back in the 80's?), a study was done by Kaiser with anesthesiologists and CRNA and they shockingly:) agreed that 90% of cases don't need supervision at all. That struck home with me. So, except for the 10% subspecialty cases, I agree with you.
Agree to disagree. We have crnas and MDAs who truly cannot do anything but bread and butter. We have crnas and MDAs who do RFAs/pain procedures, exotic blocks, and hearts without any help/supervision. Your title shouldn't define your limits. I think the healthcare industry automatically assumes competence for physicians until proven otherwise; it's the reverse for crnas and I think that's misguided.
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.
subee, MSN, CRNA
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I think that is correct for most of the OR but a CRNA is never going to be in charge of an ICU as our anesthesiologists do. We are not qualified to do that. Tefra qualifications are a rip off but I'm old enough to remember working before TEFRA and why in even came about. A lawsuit in Minneapolis by CRNA's against the MDA's forced the feds to create TEFRA. That came to bite us in the ***. We all are aware that it makes us all non-compliant since you couldn't run an OR by bending to it's stipulations. It's strictly a billing requirement to make sure that the MDA's get out if their street clothes at work.