DocHolliday

I used to provide tutoring services in basic medical sciences when I was a med student, and some of the students I tutored were nursing students. Hence, I have some direct 'exposure' to a BSN curriculum, and as a result, I can say with quite a bit of confidence that nursing school is an absolute joke compared to medical school.

Hold on there. Don't jump to conclusions. I am exceptionally generous when it comes to passing on whatever knowledge I have to the mid-levels with whom I work. I am a firm believer that it makes my job easier by having those around me know as much as possible. Any nurse, PA, NP, or even assistants who asks me about a subject will get from me as detailed an answer as they desire (and as I'm capable of giving). There is a difference, however, between asking and questioning. And you don't need to be a psychologist to know which one you're receiving.

You are mid-levels. In fact, the state legislature in my state refers to advanced practice nurses and physician assistants as "mid-levels". I'm sorry you don't like the title. Would you prefer we call you "doctor"? Yes. Nursing school is a joke. Yet CRNAs, when tabulating the amount of education they've received and comparing them year-for-year with the education of anesthesiologists, give their two years of nursing school the same level of consideration as two years of medical school. Surely you can see my problem with that. No, there is no comparison. CRNA programs teach nurses to provide anesthesia services--which almost certainly means some anesthesia-related medicine, pharmacology of general anesthetics, intubation, and so on and so forth, as well as some anesthesia trouble-shooting. They do not teach nurses to serve as physicians who have intimate knowledge of human health and disease, and who have diagnostic capacity. This is a very clear distinction between anesthesiologists and CRNAs. I can't believe I'm hearing this. On one hand, you admit that anesthesiologists have "the more intimate knowledge of the body and (medical) sciences, yet you maintain that CRNAs are trained to do everything an anesthesiologist does. So, there is but one conclusion that one can make from your statement above: That anesthesiologists possess a lot of knowledge that is of no use to anesthesia. Is there any other conclusion I should draw from your statement? That CRNA didn't have a brain fart. Obviously, she knew about paralytic agents. They use vecuronium from time to time. She flat-out didn't know what the hell I was talking about! I had to explain to her the connection between muscles and bones! And the educational disparity between physicians and mid-levels doesn't stop there. I have seen many instances when mid-levels did things or said things that clearly demonstrated a real deficiency is knowledge of various medical topics. Two other examples: During my residency, one of the staff had symptoms of a common cold, which I personally diagnosed as a cold. The ARNP started an IV and administered (without permission) a single dose of 900mg of Cleocin, along with a bag of Ringer's. I asked her what the clinda was for, to which she responded, "Sarah is feeling sick". It's as though she had no grasp of bacterial vs. viral infections, nor any grasp of antibiotics and their spectrums (clinda is not even remotely the drug of choice for bacterial URI's. She used it, despite the fact that we had ampicillin available). Mind you, she was not fresh out of her ARNP program. She had been at it for several years. As a first-year med student, just a couple of months into the year, I went to student health once because I was sick. and the ARNP asked me (after deciding that I needed antibiotics) "which antibiotic works best for you"? Even at the time, I knew that the lady didn't have a clue what she was doing. These are not the kinds of mistakes physicians make. If we make mistakes, they are absent-minded mistakes, i.e. the kinds of mistakes any human being is going to make. These mistakes by these ARNP's, were clearly a sign of knowledge deficiency.

There is a word to describe the idea I'm trying to get across, but it eludes me at the moment. What I mean by 'physician-level' is a doctor who is not subject to the oversight of anyone but the boards. You cannot be serious with this question! DO's and MD's are both physicians. DO's, however, offer--or at very least, claim to offer--a different approach to medicine than M.D.'s. And just FYI, osteopathic medicine was created by an M.D. So your question is a bad one, on it's face. Are you just saying this just for the sake of being argumentative, or do you really mean what you say here? A Ph.D. is a doctor of philosophy. An M.D. is a doctor of medicine, a D.D.S. is a doctor of dental surgery, a D.P.M. is a doctor of podiatric medicine. Do you notice any similarities between these degrees? I.e. the word "doctor"? The degree being a "professional degree" does not in any way prevent a degree from being a doctoral degree. Yes, it is possible to have a doctoral degree in a profession.

Indeed, a PhD in pharmacology is not a clinical degree. It is a research degree. What I think, though, is that a clinical doctorate in nursing is absolutely ridiculous. It's like bronzing a crushed aluminum can. A nursing degree is not a foundation on which to build a clinical doctoral degree. And there is no need for a specific doctoral degree in anesthesia (stacked on top of a BSN degree). Think about it, and compare the two: Student A goes to med school for four years and becomes a physician, and subsequently enters a four year anesthesiology residency to become an anesthesiologist. Student B goes to nursing school for two years (then works in an ICU for some period of time), then goes to a DNAP program for what, two, three years to become what exactly? What exactly is a DNAP? Why does this "doctor" exist? What the hell is a "doctor of nursing?" Now, you compared DNAP's to PharmD's (which are comparable to DDS's and DPM's, which are 'physician-level' doctors of specific branches of the medical profession). DDS's, DPMs, and PharmD's are doctors that exist to serve a unique and specific need. What need does a "doctor of nursing in anesthesia" serve that is not already served by CRNAs and anesthesiologists? You see my point? If you ask me, this idea of a DNAP degree is just another ploy to sugar-coat the nursing professions efforts to obtain the rights and privileges of doctors without going to medical school. This is fight for expanded privileges is not unique. About half the oral surgery residency programs out there now are six years in duration rather than four--the extra two years so that they can earn M.D. degrees as part of the residency. For what? It doesn't make a damn bit of difference to the oral surgeon himself or herself; the single-degree residents get the same surgical training as the dual-degree residents. It's a ploy, so that oral surgeons could more easily expand their scope of practice to include procedures that were traditionally considered to be "medical" in nature, like facial cosmetic surgery, head/neck oncology (my turf!), and so on. At least, at very least, oral surgeons acknowledged the significance of a medical degree in their plight to solidify their expanded scope of practice. Nursing, on the other hand, brazenly seeks to gain parity with physicians by bypassing the M.D. degree altogether, and instead creating some bogus "doctoral" degree in nurse-anesthesia. No, I'm aware of everything you said there, except for the topic of CRNAs implanting nerve-stimulators. Boy, they really are cocky, aren't they! That is a surgical procedure, and as a surgeon who busted his tail for four years in medical school and five years in an ENT residency working literally 80+ hours a week to get where he is, I am personally offended that some cockamamie nurse thinks he or she should have the same rights and privileges to surgically modify someone's body. As a physician, I am also offended that these nurses, advanced practice or otherwise--doesn't matter--wish to practice medicine without a medical degree.

We're not talking about the rest of the world, now are we. That aside, whatever degree a physician holds elsewhere, he or she is still a physician--with all the rights and privileges of a physician. They are not considered to be the equivalent of mid-levels. So, your point makes no sense.

I don't own the practice. But you're right, I am an absolute thrill to work for.

Wtbcrna, that's a very childish response. You need to stop looking at it as being "subservient", and start recognizeing it for what it is: a more highly trained health care professional having oversight over a less highly trained health care professional. Nobody is saying that you shouldn't be able to make clinical decisions. Nobody's even saying that you're not qualified to handle emergencies. What I'm saying is that there should be an anesthesiologist present to supervise, should problems occur that are beyond the scope of your training. That's why there are physicians who specialize in anesthesiology. Someone, a long time ago, determined that anesthesia and its associated sciences are diverse enough to warrant a physician to specialize in it. And just FYI, anesthesia is not a nursing profession, as you think. And anesthesiologists aren't dipping into your field. Hell, the concept of anesthesia was invented by a dentist (Dr. William Morton) in the 1800's, so if anything, it is dentistry that "owns" anesthesia. But do you see dentists complaining about anesthesiologists (and CRNAs) stealing their turf. Regarding my anesthesia experience: I never said that my training in anesthesia made me an authority on the subject. What I've said is that my degree and my training in anesthesia have made me well aware that it is a highly medicine-oriented specialty, and as such, there are certain aspects of it for which mid-levels with nursing degrees aren't sufficiently trained. Finally, never use the military as an example. The military is the epitome of an organization that has historically been willing to cut corners where health care is concerned.

You missed my point entirely. Let me simplify it for you: You know how dentists earn a D.D.S.? Or how podiatrists earn a D.P.M.? Dentists and podiatrists are doctors, with the same level of authority and autonomy as physicians, except their doctoral degrees are in specialized fields where there are no equivalent specialists in medicine (i.e. there are no physicians who perform root canals or treat in-grown toe-nails). That's why these degrees exist. I seriously doubt that the DNAP degree is a doctoral degree that is equivalent to a D.D.S. or D.P.M. Why should there be such a degree that awards a doctoral degree in anesthesia when there are already M.D. and D.O. physicians who perform anesthesia? Catch my point? The DNAP degree seeks to create something that is entirely redundant to the existing anesthesiologists....except for the fact that DNAP's will still have less education than anesthesiologists. And even if, by some chance, this degree sought to produce a "doctor" who had the same level of education and training as an anesthesiologist, a logical person (in charge) would say, "Well, why don't these hypothetical prospective DNAP students go to medical school and specialize in anesthesiology?" Does that make sense to you?

And not only that, I seriously doubt that the doctoral degree awarded in a DNAP is not going to be a clinical doctoral degree. It'll be more like a Ph.D. (i.e. like a Ph.D. in nursing, or a Ph.D. in pharmacology--degrees that do not grant any clinical privileges). Why? Because there are already doctoral degree that cover the field of anesthesia: M.D., D.O., and even D.D.S. Who in the hell is going to acknowledge a doctoral nursing degree in a specific discipline as an equivalent to one of the current doctoral degrees?

I don't think I'm caustic. Just very, very direct . I'm actually a very nice guy at the office, on the surgical ward, and in the OR. Speaking of which, my beeper just went off! Probably some drunk bumb who got his face broken in a fight. See? You probably won't see another post from me tonight. I'll be in the OR.....fixing this guy's face.....for free!

Well, you have to admit that the anonymity of this forum does allow one to vent. I am well aware of the fact that the nurses, PA's, NP's etc. with whom I work in the hospital could make my life miserable if I upset them! I need them to do work for me, and, being a practicaly guy, I recognize the need to pick my battles. (Believe me, though, my patients' health always comes first and if ever push comes to shove, I can certainly see to it that my orders are carried out.) Besides, they all do excellent work and I'm willing to overlook things that don't get out of hand.

Silber study showed nothing that could be used to compare CRNA outcomes vs. MDAs. I know you could probably care less what the AANA thinks, but their write clearly demonstrates why no other medical journal, but the ASA would publish this study. Actually, it did. But like all research, it has its detractors, e.g. the AANA. Of course, the conclusions of the Silber study certainly fall in line with the common knowledge that more educated individuals are better suited to perform a job than less-educated individuals. Yes, I flat out refuse to believe/have not seen it demonstrated/worked with an MDA that would change my mind to the contrary/or aware of any valid research that would suggest that MDAs are more qualified anesthesia providers. An extra four years of medical education and training are of no significance in your opinion. Oh, but your measely one year of work experience as a nurse in an ICU means a lot! I have no discrepancy saying that MDAs would be more qualified to do long term ICU care over a CRNA, but that is not what you are refering to. I don't think being an MD makes someone more qualified to take care of anesthesia emergencies. The anesthesia provider's experience counts first and foremost. "I have no discrepancy"? Look up the meaning of the word "discrepancy". Anyway, tell me why anesthesiologists are more qualified to provide long-term ICU care, and then tell me why this added qualification for long-term ICU care wouldn't translate into more qualification to provide anesthesia services? You make a clear distinction between anesthesia and medicine. As a surgeon you absolutely have no idea about anesthesia or CRNAs. Wrong! My ENT residency included an anesthesiology rotation. Although it was brief (6 weeks), I nonetheless worked at the resident level and performed the same tasks as anesthesiology residents. So I do no a thing or two about anesthesia and anesthesiology. And I can tell you with the utmost confidence that the practice of anesthesiology potentially draws on medical knowledge more than any other field of medicine, with perhaps the exception of internal medicine. I am not trying to get rid of MDAs. The MDAs I work with have all so far have been great! We all work together in a cooperative envirnoment. The scope of practice where I am doing clinicals allows for complete autonomy of CRNAs (no MDA supervision/no signing off charts behind us etc). MDAs and CRNAs can both work independently in the same environment, give great care, and with equal outcomes. That's because you your definition of "anesthesia" is sticking a tube in someone's throat and turning up the gas. Anesthesiologists are trained for far more things than you are. God forbid should I or anyone I care about find themselves in need of anesthesia services, I want the most highly-trained person performing it. And that is not you. Maybe you can answer me this: Why is that some MDs (like yourself) think everyone in the medical field is inferior to them in education/experience and otherwise? Your posts clearly support that you think MDs are the only ones qualified to give quality care. Define "inferior". I'm not saying CRNAs (or other mid-levels) are inferior, as I define the word. They have certain jobs to do. And no, I don't think physicians are the only ones qualified to provide quality care. But I do have a problem with mid-levels like you who seem to think that they are doctors, minus the doctoral degree. Moreover, I think that physicians should have oversight over everything that mid-levels do, in order to guarantee for the patients that there is someone who is as highly-trained as possible watching over their care. A medical degree is awesome accomplishment and for the most part is great education, but it is hardly some secret knowledge that MDs learn. How the hell would you know? From your nursing degree? CRNAs are taught out of the same books as MDAs, a lot of us share the same instructors as the medical students, go to the same residency sites, have the same preceptors/staff training us etc., and you think there is really going to be a difference in outcomes...No there is not and is proven day in and day out all over the United States. I have news for you, where I was in medical school, the dental students used the same texts, some of the same faculty, and even took some of their classes with us. Does that make their knowledge of medicine similar to ours? Nor does it make yours. Nurse anesthesia is speciality education from day one and MDAs have to wait until they get to residency to really start training in anesthesia. You've made some idiotic statements over the course of our debate here, but this one by far takes the cake. You are a real discredit to your profession, and my impression of the CRNA profession has diminished, knowing that someone so obtuse as you can be a member of it. Whether you realize it or not, you are saying by this statement is that someone who intends to provide anesthesia is better off without the extensive background in medicine of an M.D. or D.O. (or D.D.S., for dental anesthesiologists). What exactly do you think medical school is for, Wtbcrna? You think we are trained to treat HTN and perform DRE's, and little else? Do you not see the medicine involved in anesthesia? You obviously know some of it. Physicians obviously know a hell of a lot more of it than you. Someone before me cleverly pointed out that medical training is additive; the scope and depth of medical school better prepares physicians to handle any field of medicine than your 2-year nursing degree does. Obvisously MDAs wouldn't be able to do what they do without medical school, but it is the residency that makes a true physician not the medical school. Spoken like someone who's never been to medical school. They grant us the M.D. degree and the title of "physician" because we have shown that we have learned everything required to be awared the degree and the title. In order to practice medicine, we are required to spend merely one year after school in some sort of post-grad training program. Residency, on the other hand, is for the purpose of specialization. I am a physician who specialized in otolaryngology, not a medical school graduate who became a physician during his otolaryngology residency. This discussion is getting old. I understand fully what you are saying and I totally disagree with you, and you have no valid research to back up your arguement. No, you do not understand the points I am making. You think in a complete vacuum, with absolutely no regard for the realities around you. And as far as research goes, neither do you. Don't think for an instant that I (and the entire anesthesiology profession) am unaware of the motivations behind the "research studies" conducted (under the auspices of the CRNA profession) to show that CRNAs don't need any help from their more educated counterparts.

When I say "second guess", in some cases I am asked something along the lines of, "Dr. S., don't you think it would be better to...." or "I really think we should XYZ instead of ABC" (ABC being what I recommended or ordered). As I've said, this has happened on a couple of occasions in front of patients. I've even had a PA actually change an order I made for a post-op patient of mine without consulting me first. Believe it or not, this kind of stuff doesn't upset me. I certainly think they are out of line by doing so, but I don't get upset about it--at least, not enough to say something to them about it. (I'll admit that I'm far more willing to engage in confrontation on this forum than I am with the mid-levels with whom I work.) I hate confrontation in the workplace, so I usually just indulge their fantasy that I am required to explain my decisions to them, and just go ahead and explain my decisions to them.

I would agree that it's not the norm, but I'm a firm believer in the idea that where there's smoke, there's fire. I work with mid-levels regularly, and although I have never had a bad experience with them clinically (i.e. no royal screw-ups), I have nevertheless encountered some who were brash enough to second-guess me, and on a couple of occasions, in front of patients. I had no idea that there could exist a mid-level who'd say such a thing like they attended medical school for two years rather than four.