Private practice as a CRNA

allnurses Guide · Jul 10, 2016

The first 4 years in an undergrad are not useless. They weed out the poor students from the week ones. It is much harder to get into medical school than in nursing school. You can't expect to be a literature major and do well on the MCAT's unless you take a lot of science classes along with lit.
Second, medical school is grueling, lets give them some credit. The first 2 years is heavy on science, much more so than nursing school, and then the third and fourth years they often take call just like interns.
An anesthesiology residency is 4 years long. 1st year is an internal medicine year with call at the hospital every fourth night. When they become a PGY1, that call increases to every 3rd night, and at least 80 hours in the hospital, notwithstanding the studying that is not part of that time limit. And the 80 hour "limit" is an average over 4 weeks and does not include home call.
If you are going to dismiss any educational training, it should be the year requirement for CRNA's in ICU. This is not education, it is experience, and there is no actual standard requirement for this. I know nurses who did their ICU experience in rural areas without even running a code.
This is why healthcare is so screwed up. People do not have respect for each other's fields and give opinions that are biased. CRNA's do a great job, and I respect them very much (considering I have them as students) but I also am very aware of medical school training and respect is deserved there as well.

There is a lot of debatable material here.

1. Having done the pre-medical curriculum it has very little to do with actual anesthesia knowledge.

2. The overall acceptance rate for medical school is around 50% and the acceptance rate for nursing school applicants is about 40%. In the simplest terms it is harder to get accepted into nursing school versus medical school. As someone who has done the curriculum to get accepted for both medical school and nursing school some of the classes are harder/more intense in the pre-medical curriculum making it potentially more rigorous for most people to complete the pre-med program and get accepted to medical school. How Many People Get Into Medical School? | Kaplan Test Prep. American Association of Colleges of Nursing | New AACN Data Show an Enrollment Surge in Baccalaureate and Graduate Programs Amid Calls for More Highly Educated Nurses

3. There is no doubt that medical school has more heavy basic science than does undergraduate nursing school and most graduate nursing school programs. That doesn't mean that equates to better patient outcomes or the need for phyisicans to supervise/direct APRNs. There is a difference between having respect for someone else's education and believing that their education is superior to yours, if length and rigor were the only factors that mattered in delivering excellent patient care then an MD/PhD would be the pinnacle of education for direct patient care.

4. Intern and resident work hours vary greatly by program. I have trained medical students during their anesthesia rotations, and that particular rotation was one of the easier rotations. Just like nursing experience prior to anesthesia school medical school rotations and hours worked vary greatly.

5. Anesthesiology residency is 3 years and a 1 year internship. That 1 year of internship does not have to be in internal medicine. I have worked with anesthesiologists that did their internship in surgery, medicine, and one that did ENT internship. I have several anesthesiolgists tell me that their internship did nothing to help them prepare for anesthesiology residency. The time spent in critical care as nurse does directly relate to the skills needed for anesthesia school such as understanding vents, managing drips, complex pathophyisiolgy, fluid resuscitation etc.

6. All healthcare professionals deserve respect, but unfortunately nurses receive very little respect and physicians receive a lot.

msn10 · Jul 10, 2016

1. Having done the pre-medical curriculum it has very little to do with actual anesthesia knowledge.

Of course it does, anesthesia is heavily based in science. It is the foundation one needs to advance. You can not understand pharmacology without a basic understanding of chemistry and anatomy.

The overall acceptance rate for medical school is around 50% and the acceptance rate for nursing school applicants is about 40%. In the simplest terms it is harder to get accepted into nursing school versus medical school. As someone who has done the curriculum to get accepted for both medical school and nursing school some of the classes are harder/more intense in the pre-medical curriculum making it potentially more rigorous for most people to complete the pre-med program and get accepted to medical school.

Based on your schooling, you should know better than anyone that percentages mean nothing until put into context. You cannot get into medical school until you complete an undergraduate degree. The vast majority of nursing school applicants come from high school. Getting a BA or BS is harder than a high school diploma. Average GPA to get into medical school is about a 3.7 (and that is a BS or BA GPA) whereas the average GPA to get into nursing school is a high school GPA of 3.0, ADN school is a 2.7.

Anesthesiology residency is 3 years and a 1 year internship. That 1 year of internship does not have to be in internal medicine. I have worked with anesthesiologists that did their internship in surgery, medicine, and one that did ENT internship.

Don't know what kind of school you are referring to, but any accredited ACGME training needs to have a CBY with 12 months of rotations throughout specialities. No one would do a full year in ENT because that is a surgical specialty. ACGME and the American Board of Anesthesiology would never accredit a program like that. Our program has the following:

4 months of hospitalist rotations on medical-surgical wards
Anesthesiology
Anesthesia-directed SICU
Anesthesia pain clinic
Emergency medicine
CT and vascular surgery

I have several anesthesiolgists tell me that their internship did nothing to help them prepare for anesthesiology residency.

Then they went to a poor program. Understanding how the body works, understanding different rotations, understanding all different types of disease processes, all under the supervision of a attending and chief resident is not wasted time. I find it ironic that you would say that an 1-year ICU job is more experience than a 1-year medical rotation which is twice as many hours prescribing the very medications that nurses become familiar with.

Just like nursing experience prior to anesthesia school medical school rotations and hours worked vary greatly.

They are still more than nursing.

allnurses Guide · Jul 10, 2016

Of course it does, anesthesia is heavily based in science. It is the foundation one needs to advance. You can not understand pharmacology without a basic understanding of chemistry and anatomy.
Based on your schooling, you should know better than anyone that percentages mean nothing until put into context. You cannot get into medical school until you complete an undergraduate degree. The vast majority of nursing school applicants come from high school. Getting a BA or BS is harder than a high school diploma. Average GPA to get into medical school is about a 3.7 (and that is a BS or BA GPA) whereas the average GPA to get into nursing school is a high school GPA of 3.0, ADN school is a 2.7.
Don't know what kind of school you are referring to, but any accredited ACGME training needs to have a CBY with 12 months of rotations throughout specialities. No one would do a full year in ENT because that is a surgical specialty. ACGME and the American Board of Anesthesiology would never accredit a program like that. Our program has the following:
4 months of hospitalist rotations on medical-surgical wards
Anesthesiology
Anesthesia-directed SICU
Anesthesia pain clinic
Emergency medicine
CT and vascular surgery
Then they went to a poor program. Understanding how the body works, understanding different rotations, understanding all different types of disease processes, all under the supervision of a attending and chief resident is not wasted time. I find it ironic that you would say that an 1-year ICU job is more experience than a 1-year medical rotation which is twice as many hours prescribing the very medications that nurses become familiar with.
They are still more than nursing.

As I stated before all this is highly debatable.

1. No I didn't organic chemistry or phyics to understand pharmacology and neither do med students. I took the same pharm class as the medical students in my anesthesia program.

2. I doubt many nursing students are accepted with 3.0 GPA, especially as it can be extremely difficult to get into some nursing schools. Every RN school that I know of does not take applicants directly out of high school. Every nursing school that I have seen requires that you completed all or most of the pre-nursing requirements prior to applying to nursing school. You are free to post evidence to contradict me, but I won't just take your word for it.

3. Well I guess you will just have to be wrong then. It was one of the residents I worked with during my NA residency. I don't know the exact specifics, but this person was allowed to do a year with ENT for their intern year. The program was also accredited. This was a military program, so a lot of times the residents don't go directly to their residencies. They could have done an intern year and then went on to work as a GMO before going to residency.

4. BS. They neither went to a poor program or needed a year of scut work to do an anesthesia residency. It hasn't been that long ago since anesthesia was a 3 year residnecy and the fellowships were 6 months.

Working in the ICU is more clinically relevant to anesthesia than a year of internship IMHO. You can sit here and debate that all day long, but I have worked with anesthesiology residents, taught medical students, and currently teach SRNAs so my opinion is based on what I have seen and been told by several anesthesiologists.

5. The point of all this is still the same. We should all treat each other respectfully. I disagree that physicians should be put on an Ivory tower just because they went to medical school and residency. Furthermore, what you see posted on here and other places is the backlash from medical societies, like the ASA, who have for decades degraded CRNAs and other APRNs, lied to the public and other health professionals stating how CRNAs/APRNs are unsafe, that APRN studies are made up lies, and APRNs are only fit to work under physicians.

Every CRNA that I know works directly with physicians/surgeons/OB. CRNAs have a lot of respect for their skills and training, and most physicians that have worked with independent CRNAs/APRNs have a lot of respect for them too.

CRNAs are fighting to maintain their independence, which they have always had, while medical societies are fighting to maintain their members bottom line. The rhetoric in these fights is often nasty with a lot of opinions thrown out by both sides. What isn't debatable is that indpendent APRNs are safe and effective providers.

msn10 · Jul 10, 2016

wtbcrna

You are right, we can debate all day. However, you are taking the exceptions to the rule when saying that an anesthesiologist's CBY is useless and that one MD you knew did a ENT rotation. And Anesthesiologies residencies have been 4 years longer than CRNA's were required to get a masters. You still have CRNA's who BSN's practicing.

Wasn't debating the safety of CRNA's, I was countering Nomad's testament to MD training. It is challenging, longer than a CRNA's and now the most prestigious programs are increasing it to 5 years. They know how important that first CBY is and they are increasing it to 2 years to be a dual IM/Anesthesia or Pediatric/Anesthesia program. As anesthesia is now providing the care for a patient from clinic to post op care, the need to truly understand the whole patient, not just the anesthetic. It is a testament to the importance of anesthesia.

You can sit here and debate that all day long, but I have worked with anesthesiology residents, taught medical students, and currently teach SRNAs so my opinion is based on what I have seen and been told by several anesthesiologists.

We both have, so I do see their CBY year as very important.

All I know is that CRNA's and MD's alike bring down the profession when they ridicule each other's education.

allnurses Guide · Jul 10, 2016

wtbcrna
You are right, we can debate all day. However, you are taking the exceptions to the rule when saying that an anesthesiologist's CBY is useless and that one MD you knew did a ENT rotation. And Anesthesiologies residencies have been 4 years longer than CRNA's were required to get a masters. You still have CRNA's who BSN's practicing.
Wasn't debating the safety of CRNA's, I was countering Nomad's testament to MD training. It is challenging, longer than a CRNA's and now the most prestigious programs are increasing it to 5 years. They know how important that first CBY is and they are increasing it to 2 years to be a dual IM/Anesthesia or Pediatric/Anesthesia program. As anesthesia is now providing the care for a patient from clinic to post op care, the need to truly understand the whole patient, not just the anesthetic. It is a testament to the importance of anesthesia.
We both have, so I do see their CBY year as very important.
All I know is that CRNA's and MD's alike bring down the profession when they ridicule each other's education.

That is Nomads impression of MD training, and understanding his background I understand what he is saying.

Simply making a professions education longer does not equate to better outcomes. Similarly having more certifications does not make one a better provider or more qualified to take care of patients.

The idea anesthesia perioperative surgical home is about making more money for anesthesiologists and moving anesthesiologists further away from the OR. Independent CRNAs are just as qualified to do the preoperative, intraoperative, and immediate postoperative care as our anesthesiologist counterparts. It is debatable how much better an anesthesiologist is taking care of long term postoperative patients versus a dedicated surgical hospitalist.

I have always worked where independent CRNAs and MDAs do the preoperative evaluations, intraoperative care, and immediate postoperative care equally. Having a CRNA or MDA do these things is valuable, but trying to imply that only anesthesiolgists are qualified to do them or supervise/direct these things is a lie such as what the ASA is trying to state.

msn10 · Jul 10, 2016

The idea anesthesia perioperative surgical home is about making more money for anesthesiologists and moving anesthesiologists further away from the OR.

I have always worked where independent CRNAs and MDAs do the preoperative evaluations, intraoperative care, and immediate postoperative care equally.

How in the world is the PSH making more money for anesthesia? More and more MD's are becoming hospital employees, and the PSH is adding time to their schedule and producing less billing time. Most MD'a are not exactly thrilled with this move as they realize it is going to require more training. And you would need more training as you are now responsible for patient outcomes from the time a surgery is scheduled to post discharge. It is not just about the pre-op and post-op area.

ASA | Overview

Simply making a professions education longer does not equate to better outcomes. Similarly having more certifications does not make one a better provider or more qualified to take care of patients.

Then why bother getting your DNP or PhD? Why are APN educations all becoming DNPs? We need more time in our training to gain the knowledge. We realized that a master's just is not enough time to learn all we need to treat patients safely and to advance EBP.

allnurses Guide · Jul 10, 2016

How in the world is the PSH making more money for anesthesia? More and more MD's are becoming hospital employees, and the PSH is adding time to their schedule and producing less billing time. Most MD'a are not exactly thrilled with this move as they realize it is going to require more training. And you would need more training as you are now responsible for patient outcomes from the time a surgery is scheduled to post discharge. It is not just about the pre-op and post-op area.
ASA | Overview
Then why bother getting your DNP or PhD? Why are APN educations all becoming DNPs? We need more time in our training to gain the knowledge. We realized that a master's just is not enough time to learn all we need to treat patients safely and to advance EBP.

The ASA is actively lobbying for a change in billing specifically for the PSH. You cannot find anything about PSH that doesn't address money/billing.

A PhD has no direct clinical relevance it is a research degree by definition.

There are also no studies that I know that show improved outcomes for a DNP/DNAP APRN versus a masters prepared APRN. The DNP is designed to make leaders and educators in healthcare, to provide a degree more inline with credit hours required already by APRN degree programs, and to provide experts in EBP thereby hopefully helping reduce the time it take research to come into practice.

If there is a nursing program that is telling their students that a DNP is going to make them better clinicians than Master prepared APRNs they are lieing.

msn10 · Jul 10, 2016

he DNP is designed to make leaders and educators in healthcare, to provide a degree more inline with credit hours required already by APRN degree programs, and to provide experts in EBP thereby hopefully helping reduce the time it take research to come into practice.

The entire point of a DNP is to be able to advance clinical instruction AND increase interpretation and implementation of research into practice. It is not just about reducing the time it takes for research to get to the bedside. The very act of understanding how research should be utilized (what matters and what doesn't) is the very definition of increased clinical competency. The fundamental objectives of ascertaining whether or not research should be used is to increase patient safety (by proxy of better and safer practice) and to reduce costs. The master's programs before did not address this they way we needed to. Being safer means you are a better clinician. Cannot see how those 2 are mutually exclusive.

The ASA is actively lobbying for a change in billing specifically for the PSH. You cannot find anything about PSH that doesn't address money/billing.

As with any major change, it has to be fiscally reasonable. The authors and the creators of the PSH are almost all hospital administrators and MD's in academia (Alabama, Michigan, Cleveland Clinic, etc.) They are more focused on patient outcomes and reducing costs. The billing aspect is more about ABO models vs. antitrust laws with regards to contracts and stepping on other MD toes. If done appropriately, the training now would offset future costs for both hospitals and medical groups. The PSH is in no way intended to be a money maker. Just the opposite if not done correctly.

Its fine, I'm out again. I stayed away from Allnurses for awhile because, quite frankly, just too busy to join in the conversations. Like soap operas they don't change much and really don't help my practice or business.

allnurses Guide · Jul 10, 2016

The entire point of a DNP is to be able to advance clinical instruction AND increase interpretation and implementation of research into practice. It is not just about reducing the time it takes for research to get to the bedside. The very act of understanding how research should be utilized (what matters and what doesn't) is the very definition of increased clinical competency. The fundamental objectives of ascertaining whether or not research should be used is to increase patient safety (by proxy of better and safer practice) and to reduce costs. The master's programs before did not address this they way we needed to. Being safer means you are a better clinician. Cannot see how those 2 are mutually exclusive.
As with any major change, it has to be fiscally reasonable. The authors and the creators of the PSH are almost all hospital administrators and MD's in academia (Alabama, Michigan, Cleveland Clinic, etc.) They are more focused on patient outcomes and reducing costs. The billing aspect is more about ABO models vs. antitrust laws with regards to contracts and stepping on other MD toes. If done appropriately, the training now would offset future costs for both hospitals and medical groups. The PSH is in no way intended to be a money maker. Just the opposite if not done correctly.
Its fine, I'm out again. I stayed away from Allnurses for awhile because, quite frankly, just too busy to join in the conversations. Like soap operas they don't change much and really don't help my practice or business.

I never knew why a nonCRNA was posting on this particular forum anyways, especially when they are obviously pro ACT and anti-independent APRN.

From the AACN (this sounds very familiar to what I already stated):

In many institutions, advanced practice registered nurses (APRNs), including Nurse Practitioners, Clinical Nurse Specialists, Certified Nurse-Midwives, and Certified Nurse Anesthetists, are prepared in master's-degree programs that often carry a credit load equivalent to doctoral degrees in the other health professions. AACN's position statement calls for educating APRNs and nurses seeking top systems/organizational roles in dnp programs.
DNP curricula build on traditional master's programs by providing education in evidence-based practice, quality improvement, and systems leadership, among other key areas.
The DNP is designed for nurses seeking a terminal degree in nursing practice and offers an alternative to research-focused doctoral programs. DNP-prepared nurses are well-equipped to fully implement the science developed by nurse researchers prepared in PhD, DNSc, and other research-focused nursing doctorates. American Association of Colleges of Nursing | DNP Fact Sheet

AnesCRNA · Apr 17, 2020

On 5/22/2016 at 11:27 PM, nomadcrna said:
It's absolutely correct. Go to the AANA.com website or call them. I would assume other CRNA will chime in.
CRNA can do any procedure, any case that MDAs do. Everything from peds, to geriatrics. Every PS acuity status, SOLO. We can do any procedure from PNBs to central lines, swan ganz, TEE and more. The training is very similar. The number and type of cases are similar.
The big difference that I see is that there are more mediocre CRNA schools so you have a wider range of mediocre CRNAs. For instance if you do a program where the CRNAs are directed and then go to a practice model such as an ACT where you are supervised, it's very difficult to be a good independent CRNA.
Here is the break down of education.
CRNA:
4 years BSN
1 year minimum critical care (average is 6 years)
3.5 years (7 semesters minimum) Anesthesia
MDA:
I don't count their undergrad as it's absolutely useless (as in my daughter the literature major is in her 3rd year of med school now). They like to count it as it makes them look better.
4 years med school. First two years all science related. No clinical. 2nd two years rotations where they don't do a heck of a lot.
3 years residency which include 3 years anesthesia training.
The number and types of cases required during training are very similar. I've found that there are good and bad in both camps. The initials don't mean much.

I would argue that you should include the whole 4 yrs of bachelors degree for premed, for the same reason that you included the whole 4 yrs for the BSN; I would say that to become an MDA you need 4 yrs of bachelors, 4 yrs of medschool, 5 yrs of residency. Total of 13 years, minimum. For crna you need 4 yrs BSN, 1 yr ICU, 3.5 yrs crna school. Total of 8.5 yrs, minimum.

allnurses Guide · Apr 17, 2020

2 minutes ago, Gmilitar said:
I would argue that you should include the whole 4 yrs of bachelors degree for premed, for the same reason that you included the whole 4 yrs for the BSN; I would say that to become an MDA you need 4 yrs of bachelors, 4 yrs of medschool, 5 yrs of residency. Total of 13 years, minimum. For crna you need 4 yrs BSN, 1 yr ICU, 3.5 yrs crna school. Total of 8.5 yrs, minimum.

Physician anesthesiologists do 1 yr internship and 3 years of residency. I’m not sure where you got the 5 years of residency from. Also, CRNA school is moving towards a required minimum of 3 years and graduating with a Doctorate, but not all of those nurse anesthesia schools have made that transition or increased their time to 3 years yet.
This age old argument of who goes to school the longest is ridiculous. The physician crowd artificially increases their numbers on paper of hours spent in training while disparaging CRNA training simultaneously. What they never want to talk about is how they,as the most heavily funded speciality PAC, have never been able to show independent CRNAs are unsafe or provide inferior care compared to independent physician anesthesiologists. That’s where the argument ends.

AnesCRNA · Apr 17, 2020

5 minutes ago, wtbcrna said:
Physician anesthesiologists do 1 yr internship and 3 years of residency. I’m not sure where you got the 5 years of residency from. Also, CRNA school is moving towards a required minimum of 3 years and graduating with a Doctorate, but not all of those nurse anesthesia schools have made that transition or increased their time to 3 years yet.
This age old argument of who goes to school the longest is ridiculous. The physician crowd artificially increases their numbers on paper of hours spent in training while disparaging CRNA training simultaneously. What they never want to talk about is how they,as the most heavily funded speciality PAC, have never been able to show independent CRNAs are unsafe or provide inferior care compared to independent physician anesthesiologists. That’s where the argument ends.

I’m not taking any sides. I was simply correcting the comparison. You may be right about the yrs of residency but, nevertheless, the minimum requirement to become an MDA compared to a CRNA is more. Also, I have to say, reading the previous comments, that getting into nursing school (school to become an RN not crna) is easier than getting into medschool. It took me a while to prep and apply to med school, I applied to over 15 schools (this is prob the average amount of schools that applicants apply to), and was only offered admission to two. Now that I changed my plans to pursue nursing instead, applied to only 1 nursing school last year with the same grades, and got in. This nursing school is also one of the best in the country. Again I’m in no way implying that one profession is better than the other. I’m merely saying that the minimum requirement for one is more than the other. As far as whether or not all that schooling is necessary to practice anesthesia, I wouldn’t be able to tell you because I’m neither an MDA or CRNA.