Nurse Anesthetists: We Have the Wrong Attitude!

[gassyjon]

Hello all...

I am a long time reader, and have never been motivated to post before now. I have to admit, I'm exteremely disheartened by all these political threads both here and on SDN about scope of practice of anesthesiology! Make no mistake, I'm the first one to advocate preserving the right to practice for CRNAs, but there is an important factor we are leaving out of these discussions...the patient!

It seems as though these discussions are no longer about what's important. They read very much like a pissing match over "territory" of CRNAs vs. MDs. We need to worry less about our "rights" and our paychecks, and more about the most important person in the OR, the PATIENT!

When it comes right down to it, we all know that when a patient crumps, its GREAT to have a second mind and set of hands there. So I have to ask, what's the big deal about supervision? I for one love the idea of having an MD there to help me out if a patient cant be ventilated, or if they are in sever bronchospasm. I know that the docs feel the same way about me. Again....having that kind of team approach only benefits the patient.

I also think we have to acknowledge one thing. I know some people aren't going to like this, but MDs do have more extensive training and education than us. I for one know that the MD I work with in the heart room knows alot more about managing acute MI than I do, and if a patient starts going ischemic I am GLAD to have him there. If I was having a CABG, I would certainly want MD backup, and I think other CRNAs would be hard pressed to disagree! They supervise us because they should! I work quite frequently on the labor deck at my institution. I know I would be quite put off if RNs suddenly started putting in and managing epidurals. Why? Because they don't have equivalent education! Nonetheless, I believe it would be of benefit to the PATIENT to have the RN there to assist should a probelm arise. And if you're concerned about your paycheck, I have to ask why. It's unfair to refer to MDs as "making $700K off of CRNAs" and the like. First off, I don't know an MD making that much in anesthesia. Regardless, they go through a minimum of 12 years of training...more if they pursue a fellowship. It makes sense that they make more money. They also have a considerable burden of debt...the MD I work with has $250k in loans from undergraduate and med school combined. My debt, and the debt of most CRNAs, does not approach that. bottom line is, we make a nice living doing what we do, and most of us get a huge amount of satisfaction from it without regard to whether or not we are being supervised by an MD.

Getting back to the patient, the most important person(I want to reiterate that): I read all over this forum that there is no evidence that supervised anesthesia is superior outcome-wise to non-superivsed anesthesia. I wish this were true, because it would simplify a complex issue, but it's not. If you check out this article:

http://www.anesthesiology.org/pt/re/anes/fulltext.00000542-200007000-00026.htm;jsessionid=C2Yi8r1TJNa1YQPms0ChEn9pxFt9A19yChuQu6dWGq3PoFadx2Zq!250931426!-949856145!9001!-1

There's a pretty clear advantage to having supervision in the OR in terms of mortality. Don't trust the MDs journal you say? Well, I'm not sure I do either, but there are studies in our own journal that, depending on how you interpret them, you could conclude that there is either no difference OR an advantage to being supervised. Of course, there are problems with these studies, as with all studies, but the BOTTOM LINE is the same....there is a paucity of good evidence, and neither the CRNAs nor the MDs can make any claims either way about outcomes. It's inappropriate, and just not good science at this point in time. And even if there were good science to support unsupervised anesthesia, it would not change the central issue.

Why do I bring up the research? Just to drive home my point again. why does it matter? We should be worried about our patients, not who gets a bigger paycheck or whether or not we are supervised. The same goes for the MDs...however I would caution CRNAs....the MDs appear, to the public at least, to be more interested in patient safety than we are. Has anyone read the recent article in the Wall Street Journal about anesthesiology as a field of medicine? If you haven't you should....

http://webreprints.djreprints.com/1254400029287.html

This article was brought to my attention BY A PATIENT, along with a question about what CRNAs do to improve patient safety. It scared me when I could not answer. In the past, the WSJ has continually criticized anesthesiologists for poor outcomes, publicizing unfortunate and rare cases as routine, and thus making anesthesia practitioners as a whole look bad. With that in mind, I think that this article is a real breakthrough for anesthesiologists. In contrast, our website (AANA) reads like a childish attack on MDs (IMHO). In my opinion, publicizing this type of attitude is not the way to move our initiatives forward.

I'm done. If you took the time to read this long-winded rant, I thank you. I want to emphasize that ALL of the above goes for the "other" side of the conflict as well. I hope they have a similar voice of reason on their forums.

The patient is the important person. Ask yourself this: if you were on the table for a CABG, or if your wife of child was going under the knife, do you want your anesthesia provider thinking solely about the case, or do you want them thinking about how to thwart the MDs? Let's make a good name for ourselves and keep the patient at the center of our attention.

Jon

[fence]

I enjoyed reading your perspective on this topic. I also agree that we need to develop a better attitude toward other team members (i.e.. MDA's). I for one want some independence once I have experience but I am looking forward to working with the MDA's and learning from them. I want the backup they can give. I have always sought advice from coworkers. Two heads are always better than one. I would like to see the fences mended between the CRNA's and MDA's. I believe it will better the profession on both ends and benefit the patients vastly.

[elkpark]

I enjoyed your post and agree with your opinion. I am an advanced practice nurse (not CRNA) with a father who is a (retired) anesthesiologist, so I am v. familiar with both perspectives of this issue. I agree that always, ALWAYS, ALWAYS, the bottom line is not "turf," but best patient outcome.

I am v. good at what I do, I take myself seriously as a competent professional, and I expect others to do the same -- but I've never had any trouble differentiating between my education and scope of practice, and the education and scope of practice of the MDs who practice in the same specialty as me. I believe it just makes us look bad (and ignorant and arrogant) to give others the impression that we consider ourselves (or would like others to consider us) the equals of physicians. Sure, there are some hack docs out there; I know that at least well as everyone else here, and do everything I can to avoid them -- but even the hacks put in a he** of a lot more time, blood, sweat, and tears than we did to get to where they are, and they take on a lot more responsibility/liability. I say, God love 'em (the good ones, not the hacks ... :chuckle )

Maybe a terribly un-PC opinion for a nursing bulletin board, but so be it ... :)

[gassyjon]

glad to see that the first few replies to my post are constructive and positive....i was afraid it would be a witch hunt!

LOL

JON

[Marie_LPN, RN, LPN, RN]

Excellent thread, GJ.

[gaspassah]

hmm, where to start....

if backup is what you want, would you favor a senior crna as a backup that is not in a supervisory role but as backup for airway management or help with a unstable patient, or a mda that wants to dictate your practice on top of being your backup. i think the discussion is really about scope of practice and that many many mda groups or mda "supervisors" want to dictate what you can and cant do and limit your practice. many dont want crna's doing regional, is that an area of your practice you want to give up? not me.

if mda supervision was more of a consultation role where as a crna i had someone to go to for extremely diff case or questions on a certain management aspect i was not comfortable with, then it wouldnt be such an issue either.

i never said nor many on this board have many said we are smarter or put in more hours training, what is said is that the delivery of the anesthetic is the same and that the focus on anesthesia during training can be close to equivalent. i often raise the issue, as a resident how many mds sit at the bedside for 12 hours a night titrating gtts according to bp, svr, hr etc. yeah they may order the drug but they dont monitor the minute to minute changes throught the course of tx. i bring up this point because as critical care nurses we are trained in vigilance, assessing acute changes in hemodynamics in response to treatments. critical care is our internship or residency.

as far as territory or paycheck, for every aspect of our scope of practice that we dont fight for to expand or maintain pieces will be taken away. you may not choose to believe it, but that is delusion on your part.

ould be hard pressed to disagree! They supervise us because they should! I work quite frequently on the labor deck at my institution. I know I would be quite put off if RNs suddenly started putting in and managing epidurals. Why? Because they don't have equivalent education

so does this mean you dont think crnas should do epidurals because we dont have the education of a md? or that the md should do the epidural or spinal and we just manage the patient afterward. this is a poor analagy in my opinion, i work alot with residents right now and i have to tell you, the ones where i am are not that good. period,,medical school or not. i wouldnt let them touch one of my family members. i know several crnas that do ob only i would take one of them anyday. and that goes for full fledged mda too.

as for the money issue, i dont really care what they make, just dont limit the opportunities and my scope of practice to limit the amount i can make. the mda lobby does this everyday on capital hill, and yes we do it to, to protect our rights, if we didnt counter their efforts, we would just be bag squeezers like aa's.

as far as patient safety goes, all the keystone articales reviewing patient safety in relation to anesthesia provider has flaws. your attack on the aana website and the presenting of pro anesthesia article which by the way does not include a response or comments by the aana, therefore it's biased with only one viewpoint. i often visit the aana website and patient safety is a large and key part of its design and focus. your presentations and arguments lead me to question whether you really are a crna or a md resident or an aa. you dont appear nor present yourself as a very pro crna person. just my opinion

Ask yourself this: if you were on the table for a CABG, or if your wife of child was going under the knife, do you want your anesthesia provider thinking solely about the case, or do you want them thinking about how to thwart the MDs?

first of all i want the person thats best at his job, not his credentials.

secondly, if a practitioner of any specialty doenst have the patient as his primary concern at this time, then they are in error. you are causing confusion and blurring the lines between patient care and political/professional issues. yes the patient is the primary issue, the politics of thwarting the md or crna are not, at the time of caring for the patient. again give me the best practitioner, not the person who went to school the longest, or has the most letters after their name.

[UTRN2005]

Just curious but where did you go to school. Correct me if I'm wrong but according to your profile your DOB is in 79 which would make you 26. You also said you had been a CRNA for 2 years meaning you graduated the program at 24. Meaning you had to start at 22. I'm assuming you got your BSN straight out of high school which would have meant you had to graduate college at 22. Where did you fulfill your ICU requirement. Not trying to be rude but I'm just confused. Thanks

[fence]

I want to do everything with in the scope of practice of a CRNA. This doesn't mean I do not want a great give and take working realtionship with the MDA's. I refuse to paint all MDA's with a wide brush and hope they would not do the same with CRNA's. And I agree that I would want the most qualified practitioner to take care of me regardless of credential. But if there is a team approach how could it be any better.

I will admit there are DOC's I haved worked with in the ICU that I would wish on my dog, but there are others I would bend over backwards for.

[gaspassah]

But if there is a team approach how could it be any better.

i am not advocating anti team approach, i am advocating anti "supervision" in the context of practice limitations. i dont have a problem with mdas. i dont have a problem working side by side with mdas. i have a problem with mda monopoly of anesthesia practice and their fundamental idea that anesthesia is the sole realm of medicine and that a crna cannot function without "supervision".

to have an mda dictate and prescribe your anesthetic plan is NOT teamwork.

if i need someone to consult about a complex medical condition in relation to an anesthetic plan then that is teamwork.

if were to choose to do an intersternocleidomastoid block for shoulder surgery and the mda tell me i cant because its not policy or he's not comfortable with that, that is practice limitation (lets remember that the docs have more influence in hospital policy than anyone else). if i feel its reasonable and have the necessary skill to do it, and manage acute complications and it's gonna be in my patients best interest, then i should have that right (with patient consent of course).

to me, these are the factors about "supervision" i dont agree with.

billing and anesthesia for outpatient and pain management, that's another issue, related yes, but not MY big concern with supervision.

[maturner]

"This article was brought to my attention BY A PATIENT, along with a question about what CRNAs do to improve patient safety. It scared me when I could not answer."

I cannot believe that a practicing CRNA could not explain to a patient that CRNAs provide quality safe anesthesia by utilizing evidenced based practice guidelines provided by research performed by CRNAs as well as MDs, through continuing education, and recertification. The answer simply does not need to be more complex than that!

With regards to clarifying the information the WSJ article failed to mention:

The APSF was the result of the vision of Ellison C. (Jeep) Pierce, Jr., M.D. while he was serving as President of the American Society of Anesthesiologists (ASA) in 1985. The formation of a foundation with the stated goal that "no patient shall be harmed by anesthesia" and whose Board of Directors included anesthesiologists, certified registered nurse anesthetists and other nonphysician health care professionals, leaders of the pharmaceutical and equipment industry, representatives of the insurance industry, legal profession, accrediting agencies, and government, was--and remains--unique among all of American medicine.

Trying to make a point with flawed information is bad practice.

Using flawed information in the practice of anesthesia is downright dangerous and greatly compromises patient safety.

[fence]

I am not advocating supervision at all. I am advocating teamwork nothing more nothing less. Like I posted earlier. I want to be able to do everything I will be licensed to do. I want autonomy but I also want to be able to bounce things off someone be it a CRNA or MDA. I will however show each respect.

[gassyjon]

sigh.

i posted the same thread over at the med student forum, and noone has yet questioned my credentials, but for those that must, I graduated high school a year early. I had a 7 year plan, which I fulfilled. I did my ICU time at the University of Rochester/Strong Memorial. Beyond that, I guess I can't prove who I am, so I guess you'll have to decide what to believe yourself. I'm not going to protest any further.

I don't have a negative or anti CRNA attitude. I am against our attitude. If you take a look at our website as opposed to the ASA website, there is a huge, huge difference in how we go about trying to adavnce our issues. i agree with the points made on the AANA website, but the way it is presented is all wrong. This is not an attack. This is my opinion. I stand by it no matter how much I may be flamed by overzealous, power hungry CRNAS on this forum. The same goes for gaspasser.com. It reads like something a jealous child would write!

I want to maintain our right to practice as much as anyone else, but I refuse to do it at the cost of superior patient care. I have no intention of ever supporting the notion that MDs should not be included in our practice. Everyone is supervised by someone, including the MDs. Furthermore, the vast majority of MDs out there work TOGETHER with CRNAs, deveoping an anesthesia plan rather than rejecting CRNA input out of hand. If that IS the case where you work, you need to find another job someplace else. I enjoy working with the MDs at my institution, and we work together to acheive the best possible patient outcome. The vast majority of CRNAs out there have a similar experience. Again, if your work experience is different, and you have been an adult about trying to change it, and have been unsuccessful...then you have noone to blame but yourself for staying. OF COURSE THERE ARE BAD APPLES AMONG MDs. REMEMBER though, there are bad apples among CRNAs as well.

That's all I have to say. I refuse to allow this to disintegrate into another CRNA vs. MD debate. It's been said, it's old, it' s tired. It's about our attitudes and patient care. Nothing else. I WILL NOT respond to any further inflammatory, attacking, or malicious responses. Seeing this is a public forum, You have the right to speak your mind, but know if it is not in the form of constructive discussion, I will not respond, and will request that the thread be locked.

Thanks for the support to those who have given it, and even to those who disagree. I just won't be pulled into a childish pissing match.