How do CRNAs/SRNAs benefit anesthesiology residents?

loisane · Jun 17, 2004

If you want to practice anesthesia with the rights, priviledges, respect and recognition of an anesthesiologist, go to medical school and finish a residency in anesthesiology. And if you want to be a CRNA, with all the rights, priviledges, respect and recognition of a CRNA, by all means, good luck, it's a worthly and impressive goal also. But to me, it seems wrong, if you train to be a CRNA and then try to legislate your way to being treated like an anesthesiologist.

I know you are engaging multiple conversations, but there is part of your post I simply must respond to. As always, I am offering the truth as I see it, and encourage all to do their own research, which I feel will validate these facts.

Believe me when I tell you that my response is motivated by passion, and not anger. I hope you have read enough of my postings to know that. This cyberspace communication is tricky at times!

Are CRNAs trying to expand their scope of practice through legislation? The answer is an emphatic NO. This line is pure ASA propaganda. Here is my reasoning.

I don't think there is any disagreement that nurse anesthetists were the first health care professionals to specialize in anesthesia. So it follows logically that nurse anesthetists "did it all" without supervision. What we need to determine is when/if did this notion of "supervision" begin?

Many communities who now have anesthesiologists were served only by nurse anesthetists, even as recently as the 1970s. The first anesthesiologists that came to these communities were not there to supervise. They functioned as an extra resource person, what you might call a consultant. I know this for a fact in my community, because I have family that experienced this transition.

I think it isn't a stretch to assume this is the same thing that happened everywhere. After all, all 50 state have nurse practice acts that allow CRNAs to perform anesthesia, and none require these CRNAs be supervised by an anesthesiologist. CRNAs have always been the primary hands on anesthesia provider in this country.

Most CRNAs were employed by hospitals. For Medicare patients, hospitals get paid under part A. So part A is where they recouped their CRNA related costs.

Physicians are paid under Medicare part B. When employment patterns started changing, and some CRNAs were no longer working for hospitals, rules were made to allow CRNAs to bill under part B as well.

There were abuses. Anesthesiologists were contributing very little to cases, and sometimes not even in the building. Yet they billed under part B for their services. There was a fortune to be made, if an anesthesiologist was willing to be this unscrupulous. Anesthesiology became a very popular specialization.

In the meantime, the hospital continued to bill under part A for their employed CRNAs, who had done the work. About this time there was beginning to be the call for health care reform, cost containment, etc.

So the TEFRA rules were born. These are 7 steps that an anesthesiologist must perform in order to bill for anesthesia under Medicare part B. The rules were designed to decrease billing fraud. They NEVER were meant as standards of care. To my knowledge, there was never ANY research done that said "Oh, to be safe, we need anesthesiologists to do this and that. These just aren't things CRNAs should be doing". Instead the intent was "If you are going to charge us for a service provided, then we want documentation that you have at least contributed enough to this case to deserve that payment."

This is our current system. If an anesthesiologist jumps through the 7 TEFRA hoops, he can bill for his services under part B for something called "medical direction". If the anesthesiologist is involved, but doesn't complete all 7 TEFRA steps, he can still collect under part B for "medical supervision" .

The hospital can still bill for CRNAs they employ under part A. But, remember, there is no law anywhere requiring anesthesiologists be involved at all. So what about hospitals who employ CRNAs, and choose not to use the services of an anesthesiologist? Well, that is fine, and can be done.

So what was all the bru-haw-haw about a few years ago? Part A rules included language about physician involvement as a pre-requisite for payment. Some surgeons expressed reluctance to be the "physician" of record. This was despite numerous court cases that have clearly shown that the surgeon's liability does not increase when working with a CRNA.

AANA lobbied to get this language removed. It was just a way to appease the surgeons, and make them feel less threatened, about a system that was perfectly legal, and within policy. Personally, I believe the reaction was way out of proportion. When you have a patchwork of policies, that has evolved over time, you are bound to get inconsistencies. This was just an attempt to clean up the language, and make things more coherent.

Remember, in the beginning, it didn't have a THING to do with anesthesiologists. No where in law or policy are CRNAs required to work with anesthesiologists. But ASA sure did paint that sort of a picture.

It is pure ASA language to say that CRNAs are trying to increase their scope of practice through legislation. The supervision issue (which was about policy, not law), was about MAINTAINING our scope of practice. I know of NO legislation whose aim is to increase CRNAs scope of practice. We ALREADY have these rights under law. INSTEAD, what we have are legislative efforts to REDUCE our scope of practice. Florida, and New Jersey as examples.

Of course, you have a perfect right to a belief that CRNAs have too much scope of practice, and it should be reduced. But you, ASA, or others should at least be honest about the debate. CRNAs are not asking for more, you want us to have less.

Nurse anesthetists make a big deal about our history. As a profession, we have been doing this along time. We are not a bunch of cracker jack nurses who decided we wanted to play doctor, and tried to sneak our way into a physician specialization. It is much easier to make a case for the reverse. When you look at the big picture, one could say that it is anesthesiologists who are trying to play nurses.

Hope you're still with me, I know this is long winded. But these are very complex issues. I recommend the book "Watchful Care" by Bankert for the history of nurse anesthesia. It has been awhile since I read it, but I am sure it would have a section of this, with references. Or, I am sure this is also in the anesthesiology literature, if a person were to dig for it.

If you meant something different by "legislate your way to being treated like an anesthesiologist", then my appologies for this lengthy lesson. But these are important issues, all the same, and maybe someone else benefited from the summary.

loisane crna

versatile_kat · Jun 17, 2004

... and maybe someone else benefited from the summary.

loisane crna

I know I sure did!

That was one of the most clear and concise background's into the CRNA/MDA debate I've read yet. Thank you as always, loisane, for adding your insight's. They are always appreciated.

alansmith52 · Jun 17, 2004

I'd like to just copy that summary off and hand to anyone that asks me about my scope family,frieds and foes. I am getting sick of deffending my self and sounding self consious. do you think you can fit that on a buisness card :)

alansmith52 · Jun 17, 2004

the foundation of the AANA is a silly refrence for the beggings of Anesthesia as a profession. come on now.

alansmith52 · Jun 17, 2004

this forum has sure evolved. I remember back when there was less than 10 of us or so. I like the diversity now but it sure can get heated. which I also like. just an observation as to how fast these internet thangs grow. why back when I invented it... :)

Pepino · Jun 17, 2004

this board is a microcosm of the nursing profession. we bicker, *****, and moan with eachother--this represents the crux of the issue as to why nurses, even though there are three some-odd-million of us, can't band together for a shared purpose.

btw, if the working conditions at a hospital affiliated with the Wake Forest residency program are insufferable, the anesthetists employed there are free to leave. Again, this thread just adds credence to the importance of minding your own business--go to work, do your job, keep your mouth shut, and go home at the end of the day.

loisane · Jun 18, 2004

Again, this thread just adds credence to the importance of minding your own business--go to work, do your job, keep your mouth shut, and go home at the end of the day.

Oh, no, no, no. Don't feel like that! Get informed, get involved. It is YOUR profession. Don't just sit back, and let other people make the decisions that are going to define YOUR profession and YOUR life!

Now, if you were talking about a coping mechanism for a less than ideal work situation, with which you are stuck because there are outside forces making it difficult to leave for another job, then--I hear ya. We've all been there. But hopefully, that is a temporary condition. And it still doesn't stop you from keeping your own mind active, gathering information, making your own opinions, and planning for a better future.

Nurses can do this. We have to.

loisane crna

Athlein1 · Jun 18, 2004

Loisane,

Thank you so very much for your informative post. We SRNAs are just plain lucky to have you on this board!

TejasDoc · Jun 18, 2004

Loisane, you had so much to say, I can't really comment on it all, so I've kind of bitten of chunks and pieces. As always, your comments were great.

Are CRNAs trying to expand their scope of practice through legislation? The answer is an emphatic NO. This line is pure ASA propaganda. Here is my reasoning.

I'm not sure if this is totally true, and I don't think it's necessarily propaganda. I think you're right that it's something the ASA likes to say, but we'll get to that.

I don’t think there is any disagreement that nurse anesthetists were the first health care professionals to specialize in anesthesia. So it follows logically that nurse anesthetists “did it all” without supervision. What we need to determine is when/if did this notion of “supervision” begin?

You're right, as a group, nurses were the first to specialize in anesthesia. No arguments there. Anesthesiologists and supervisors of anesthesia care did come around later, leaving a gap where nurse anesthetists were not supervised. Having conceded this, will you concede that surgical / anesthesia care in the 21st century bares little resemblence to the surgical / anesthesia care provided during this period where there were very few anesthesiologists? That surgeries and anesthesia have become increasingly complex and that while yes, anesthesia is safer now than it has ever been, it is not because the anesthesia itself has gotten easier, but because we know so much more now than we ever have.

Many communities who now have anesthesiologists were served only by nurse anesthetists, even as recently as the 1970s. The first anesthesiologists that came to these communities were not there to supervise. They functioned as an extra resource person, what you might call a consultant. I know this for a fact in my community, because I have family that experienced this transition.

These communities, these were not major metropolitan areas were they? My experience here is somewhat limited, having lived in many cities over the course of my life, but having spent the vast majority in cities with a population over 1 million. So here is my question regarding this statement, do communities that are served only by CRNAs choose this? Or are they unable to attract an anesthesiologist, but if they could they would? Are there hospitals that only have CRNAs practicing as a matter of hospital policy? Do they turn away physicians because they choose not to utilize anesthesiologists for anesthesia services?

I think it isn’t a stretch to assume this is the same thing that happened everywhere. After all, all 50 state have nurse practice acts that allow CRNAs to perform anesthesia, and none require these CRNAs be supervised by an anesthesiologist. CRNAs have always been the primary hands on anesthesia provider in this country.

From what I've read, this is right, no state laws or nursing boards require a CRNA to be supervised by an anesthesiologist. But I am also under the impression that many states require a CRNA to work under the direction/supervision of a physican/podiatrist/dentist ... is this correct? And as far as I've been able to find, these requirement are not about reinbursement, not at all.

There were abuses. Anesthesiologists were contributing very little to cases, and sometimes not even in the building. Yet they billed under part B for their services. There was a fortune to be made, if an anesthesiologist was willing to be this unscrupulous. Anesthesiology became a very popular specialization.

There's a fortune to be made in anesthesia if you follow all the rules too. I just cannot imagine that the ability to bill for things you may not actually have done, and make a fortune doing so, factored that much into what medical students chose to be their medical specialty. I consider myself about run of the mill when it comes to my knowledge of how physicians get paid to do what they do, at least at my level of training. And I know just a little more than NOTHING. I know anesthesiologists make a good living, and they have a comfortable lifestyle (so do dermatologists, radiologists, ophthamologists, plastic surgeons). Anymore than that, and I'd just be guessing. The unscrupulous ability to make money never once factored into my decision.

So what was all the bru-haw-haw about a few years ago? Part A rules included language about physician involvement as a pre-requisite for payment. Some surgeons expressed reluctance to be the “physician” of record. This was despite numerous court cases that have clearly shown that the surgeon’s liability does not increase when working with a CRNA.

This may change I guess if being the 'physician of record' has only something to do with reimbursement, and nothing to do with state regulations regarding physicians supervising CRNA care. Assuming this is true, in those states, where the surgeon is the supervising physician, how does his/her liability not increase?

Remember, in the beginning, it didn’t have a THING to do with anesthesiologists. No where in law or policy are CRNAs required to work with anesthesiologists. But ASA sure did paint that sort of a picture.

Not anesthesiologists, but physicians ... I think. And at the VERY LEAST, is it not a stretch to say that in those states where supervision by a physician is require, should that physician not be an anesthesiologist?

Nurse anesthetists make a big deal about our history. As a profession, we have been doing this along time. We are not a bunch of cracker jack nurses who decided we wanted to play doctor, and tried to sneak our way into a physician specialization. It is much easier to make a case for the reverse. When you look at the big picture, one could say that it is anesthesiologists who are trying to play nurses.

I never said you were a cracker jack nurse or anything like it. I do believe this though, too much emphasis is placed on the history. It's used too much like a professional qualification, which it is not. It is very true that if you go back 100 years, you will be hard pressed to find yourself a physician specializing in anesthesiology and you would find an abundance of nurse anesthetists. But, I think you will also admit that there are many things that were done a 100 years ago in medicine that we would never do in a million years today ... we just know better now.

If you meant something different by "legislate your way to being treated like an anesthesiologist", then my appologies for this lengthy lesson. But these are important issues, all the same, and maybe someone else benefited from the summary.

Don't apologize ... if nothing else, I learned something about medicare billing. Really great post overall. I guess this is what I meant by 'legislate', and maybe I just used the wrong term. I think anesthesiologists do not see themselves as having issues with supervision, scope of practice, what some states will let them do and what other states won't, what some hospitals say they can do, and what others say they cannot, how they can bill medicare, etc. Let's just call these 'practice priviledges' to make it easy. I also don't think anesthesiologists have issues with how much they're paid compared to CRNAs, they as a general rule, make more. So this is how I think anesthesiologists might see it, and I'm really only guess here (honestly) ... they see it as though CRNAs want the 'practice priviledges' and pay of a anesthesiologist, but instead of going back to medical school and doing a residency, they lobby to have Medicare rules changed, and lobby changes in policy, such as those regarding office based anesthesia, like in Florida (I think).

Anyway, I'm getting so tired, it's hard to keep my head from hitting the keyboard. Trying to make a cohesive argument is getting to be more effort that I'm really interested in trying to expend. If my post was off in some way, I'm going to blame it on sleep. Ask me tomorrow, I can try to clarify. Thanks for engaging me on the issues, I'm enjoying the discussion.

TD

gaspassah · Jun 18, 2004

That surgeries and anesthesia have become increasingly complex and that while yes, anesthesia is safer now than it has ever been, it is not because the anesthesia itself has gotten easier, but because we know so much more now than we ever have.

this statement is right and wrong. the reason anesthesia became so safe had nothing to do with anesthesiologists and supervision, but advances in drugs used ie more cardiac stable meds, monitoring equipment etc. at one time there were no pulse oxs, no ekg, all you had was a blood pressure cuff, your finger to palpate the pulse, and you looked into the patients eyes to try and determine anesthesia plane by pupil size. please do not try to say anesthesiologists were the saving grace of safety in anesthesia care, it just aint so.

I am also under the impression that many states require a CRNA to work under the direction/supervision of a physican/podiatrist/dentist

only in the sense that someone has to "order" the anesthesia. these doctors are not responsible nor are they involved in the delivery or liability of the anesthesia care.

This may change I guess if being the 'physician of record' has only something to do with reimbursement, and nothing to do with state regulations regarding physicians supervising CRNA care. Assuming this is true, in those states, where the surgeon is the supervising physician, how does his/her liability not increase?

the surgeons have no liability related to anesthesia, this has been shown through countless lawsuits. they operate we anesthetize. they are the doctor of record only to the sense a physician had to "order" (for a lack of a better word) that someone anesthetize the patient. at least this is how it was explained to me.

Not anesthesiologists, but physicians ... I think. And at the VERY LEAST, is it not a stretch to say that in those states where supervision by a physician is require, should that physician not be an anesthesiologist?

see above 2 posts, i know it's hard to believe but states do not require your services. this is not meant to be ugly but true. the delivery of anesthesia does not have to involve mdas. i know what you THINK is important but law does not agree with you.

they see it as though CRNAs want the 'practice priviledges' and pay of a anesthesiologist,

what priviledges are you taking about. the priviledge of practicing anesthesia. anesthesia again is not the sole domain of the anesthesiologist. law has shown it is the practice of both nursing and medicine.

again i think this whole argument boils down to a couple of things.

1 mdas think anesthesia belongs to them, no changing your mind you are what you are.

2. IF they have to work with CRNAs then they feel they must supervise.

again you cant change what dont want to be changed.

3. mdas feel a threat to loss income from crna competition, fair enough

4. crnas have and do practice safe anesthesia everyday without input from mdas and without bad outcomes.

5 crnas are not mda wannabees. if i had wanted to be a doctor i would have.

you can see the difference in care provided by each person. i'm not saying better just diff.

but i cant say anything better than loisanne, i'm sure she will respond and clarify, and correct me. i just felt a need to respond to some of these questions.

d

georgia_aa · Jun 18, 2004

this statement is right and wrong. the reason anesthesia became so safe had nothing to do with anesthesiologists and supervision, but advances in drugs used ie more cardiac stable meds, monitoring equipment etc. please do not try to say anesthesiologists were the saving grace of safety in anesthesia care, it just aint so.
d

This is perhaps the most absurd statement that I've seen written on this forum to date. How did all of these wonderful advances you mentioned happen?? Was it through the ground breaking research done by CRNAs?? No, these things are developed largely by anesthesiologists and other physicians working in consort with the companies that fund their research. Do you think a drug company just comes up with an idea, develops the drug on their own, gets FDA approval and then it just lands in your anesthesia cart so that you can continue your proud 100 year tradition of safe anesthesia care?

I work side by side everyday with an anesthesiologist responsible for most of the early animal studies on Fentanyl. Another on our faculty was instrumental in developing Milrinone. Another brilliant young cardiac anesthesiologist is fast becoming famous for ground breaking work he is doing in the area of coagulation issues during CPB. The BIS monitor was largely developed thru work done by another one of our attendings - and on and on and on....

How many discoveries that change the way we practice anesthesia everyday have come from the CRNA camp?? How many CRNAs have secured NIH grants for their research?? You get my point??

jwk · Jun 18, 2004

this statement is right and wrong. the reason anesthesia became so safe had nothing to do with anesthesiologists and supervision,

The statement was absolutely CORRECT. He didn't say anything about supervision, did he? He said it's because we know so much more than we used to. It's a simple statement - one has to wonder why you read so much else into it.