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.

What makes you think I have so much free time? Because I can spend five minutes here and there throughout the day to respond to posts on a message board? I'm not in the OR every minute of every day, just for your information.

I'm a doctor, and let me tell you this: If I caught the PA in my office misrepresenting her training to my patients like that, I'd personally see to it that she was let go. If I owned the practice, I'd fire her on the spot. Boy, I'm learning a lot about mid-level providers by reading the posts on this forum. I always knew that they had a hang-up about not being doctors. I was unaware that this hang-up was so extensive that they'd try and fool patients into thinking they were pseudo-doctors. What the PA told you mother was patently untrue. Not only is PA school half the duration of medical school--meaning that they don't cover the breadth of medical topics covered my medical students, the topics PA schools do cover in the two years are not even covered in the same level of detail.

At most, the study's conclusions support the proposition that certain facilities would benefit from having a board-certified anesthesiologist in the Intensive Care Unit. This might result in the "rescue" of some patients who have undergone elective cholecystectomies and transurethral prostatectomies and developed life-threatening postoperative complications. The Silber study's conclusions have nothing to do with nurse anesthetists or the nature of who may supervise, direct, or collaborate with nurse anesthetists. At most, the study concluded that anesthesiologists may play a clinically valuable role in caring for postoperative complications. The study, however, did not involve examination of the outcomes of anesthesia in the operating room. WTBCRNA.... First off, as a physician, I am not particularly interested in what the AANA thinks about a study. Nurse anesthetists and their governing bodies are not an authority on the practice of anesthesia. Anesthesiologists and the ASA are. Moreover, even if what you said above were the only thing the Silber study rightfully demonstrated, that in itself is proof that CRNAs cannot be left alone without some sort of drop in quality of care under certain circumstances. Nobody's saying that CRNAs aren't able to handle routine anesthesia (and yes, "routine" complications). What I am saying, and what anesthesiologists are saying is that it's the complicated things they are not as qualified to handle as anesthesiologists are. I mean, do you just flat-out refuse to accept that a physician with four more years of training than you knows a thing or two more about the practice of anesthesia and its associated sciences? You think that you, a nurse who spent 28 months in an anesthesia masters program, is going to have the same scope and depth of knowledge as a physician who spent 48 months in a residency program? The conclusion to be drawn from this study is that, although the presence of board-certified anesthesiologists may not make a difference in the operating room, it may make a difference in the failure to rescue patients from death or adverse occurrences after postoperative complications have arisen. This conclusion is in keeping with the expanded role that anesthesiologists have identified for themselves in post-operative care.... My point exactly. Anesthesiologists, because they are physicians who have, unlike CRNAs, intimate knowledge of human health and disease, are better able to manage complicated situations. This Dr. Pine character certainly is splitting hairs, isn't he. Like you (and other CRNAs), he seems to view "anesthesia" as pumping some poor sap full of Diprivan, sticking a tube down their trachea, cranking up the gasses, then turning everything off and extubating when the procedure is done, and making sure the patient is waking normally inthe PACU. After that, according to Dr. Pine, the provider administering the anesthesia can dust off his or her hands, because he or she is done and no longer responsible. Well, anesthesia is a little broader in scope than that which CRNAs are trained for....as the Silber study seems to demonstrate.

She hit the nail right on the head. Look, let's be honest here.... The only reason your job is around today is because you work cheap compared to anesthesiologists. You're not the best anesthesia providers. You're the cheapest. I cannot imagine any hospital board actually concluding that they'd rather have nurses than physicians handling their patients' anesthesia needs. They are making a judgment call based on money. These hospitals just cannot afford anesthesiologists. That's why the vast majority of hospitals whose anesthesia services are provided soley by CRNAs, without anesthesiologist oversight, are rural hospitals, i.e. hospitals that have to pinch pennies. Hospitals in more developed areas, i.e. hospitals that have more money--and more complicated patient pools, invariably want anesthesiologists in the picture.

"The main difference is that CRNAs bring compassion and human touch to the anesthesia setting"? That is such a wishy-washy comment, you know that? Why don't you go ahead and define "compassion" and "human touch" for us, and tell us how it is you conclude that anesthesiologists fail to practice their specialty of medicine without compassion and human touch. Why don't you tell the original poster the real difference between CRNAs and anesthesiologists? You know, like anesthesiologists being doctors and CRNAs being nurses; like anesthesiologists spending four years in anesthesiology residencies (including a year of internal medicine rotation); like anesthesiologists being experts in critical care medicine and pain management.

This profession? This profession? You don't make any distinction whatsoever between CRNAs and anesthesiologists. You think they are identical entities, except with different degrees. As for your M.D., Ph.D. point, I know what you were trying to do, but it was a lousy example. There is no degree above an M.D. (or a D.O., D.D.S., D.P.M., or any other doctoral degree) that bestows upon someone any supervisory role. Once you have earned a doctoral degree, anyone who has any supervisory role over you does so because they have been appointed head of a department, or because they own the entire business. Again, your MD/PhD example was a poor one. Finally, I am not ignoring the research to which you refer. I am questioning their implied assertions that there is no difference between CRNAs and anesthesiologists. Just FYI, here's a study that showed that anesthesia services are better when anesthesiologists are involved: http://www.ncbi.nlm.nih.gov/pubmed/10861159?dopt=Abstract The study found the following: "2.5 excess deaths/1,000 patients and 6.9 excess failures-to-rescue (deaths) per 1,000 patients with complications" when anesthesia services weren't directed by anesthesiologists. Did you see me throw this article in your face and claim it to be proof that I'm right, as you did with your pro-CRNA research references? It certainly would have been useful to my argument, but I omitted it because, just like the research to which YOU refer, it has some deficiencies. So, instead, I am going by what is an obvious difference between CRNAs and anesthesiologists: education and training. Anesthesiologists have superior knowledge and superior training, and that makes them better. You know, come to think of it, I did have one bad experience with a CRNA. I was in the OR, performing an open reduction of a fractured mandible, and the patient's masticator muscles were flexing and preventing me from reducing the fracture. So, I told the CRNA that I needed the patient more relaxed (i.e. paralyzed) becuase I couldn't approximate the bone ends. The CRNA responded with a smart-alec comment, saying "We don't have bone relaxers". I know she was not being sarcastic or making jokes, because I had to inform her of the fact that the muscles were pulling the bone apart. After I told her, her response was a somewhat surprised, "Oh, oh. Ok". Does this experience shape my view of CRNAs? Of course not. But it does--and rightfully so--raise an eyebrow. I've never heard such an idiotic comment from an anesthesiologist in similar situations, nor would I ever expect to hear such a thing from them.

My friend since 1st grade is now done with his 2nd yr of med school. He has shown me what he is tasked with learning and knowing. It is insanely in depth! True, some of the residents will forget this stuff by the time the ICU comes around, but how many nurses can accurately recall pharmacodynamics after school? For the most part they have their knowledge bank correct and I learn something from them every day. I also just completed an advanced physiology class (using medical student text) for CRNA school and it was damn hard. The demand placed on the BSN student to learn their physio and pharm however, pales in comparison the their doctor counterparts. Point being, yes we will learn the same theories and principles, but I believe the doctors will have more depth and reinforcement on all aspects REGARDING THE PERIOPERATIVE ANESTHESIA PROCESS. The main reason for this fight to opt out and do away with the MDA is crazy. I have a feeling some of it is due to the ACT model and CRNA 's getting frustrated with that type of smothering. But for the most part, it would be good to have an MDA around. Sure, there are scenarios where the CRNA can and does do everything. But what about the ones where the pt. is deteriorating and the surgeon can't offer help, and your elder CRNA cohort(if there is one there) can't work it out either, and there is no MDA in house or on call. Then who suffers? Most of the CRNA's i've talked with and shadowed are happy with thier collaboration with the MDA's and are given a good amount of latitude, and consistently comment on how much they enjoy their job. The exception is the CRNA essentially feeling like a tech and strictly following orders. If there are any CRNA's still posting here, feel free to correct me on the above if I'm way off. I don't think anyone should treat a CRNA like a tech. And I certainly hope anesthesiologists don't either. They do have some troubleshooting abilities. What concerns me, though, from reading many of the posts from the CRNAs here is that they think they know everything an anesthesiologist does. People who think they know everything there is to know are the most dangerous people to deliver health care. They are far more likely to resist outside help. Doc Holliday: I don't believe that a CRNA is practicing under your license. Your liability from anesthesia is dependent on the extent that you choose to direct the anesthetics' delivery, whether by CRNA or MDA. On that note, it wouldn't be in your favor to order the anesthetist just to reaffirm your order on the totem pole, as that is what the tone of your comment suggested. https://www.aanafoundation.com/uploa...iefsp89-93.pdf I made that comment to which you refer simply to make a point. The CRNA, at least where I work, IS working under my license. If he/she screws up, I bear some of the blame. In reality, it is rare that I talk to the CRNA (or anesthesiologist) about the anesthesia plan. Occasionally I request muscle relaxants, or let them know that the patient isn't anesthetized deeply enough, but that's about it. That comment aside, Doc has been completely reasonable in his recounts and narration of his thoughts, yet people here are blatantly missing the point and looking silly, or poking their heads in to throw a jab at a doctor that "dared to come here" and give his 2 cents on the subject. His replies may be direct and unabashed, but it is the other posts that are laden with barbs. And Dr.Nurse2b, if you are going to make a case for us, take the time to get the facts right. CRNA: 4 yrs BSN, 1 yr ICU, 27-36 months CRNA school = 7.5-8yrs. MDA : 4 yrs undergrad, 4 yrs med school 4 yrs Anes. residency= 12yrs. I would also add to that the different nature of medical school from nursing school. Again, medical school creates physicians. Nursing school, on the other hand, creates nurses. From there, it is simply impossible for the two different entities to go on to receive the same training and same qualifications to provide anesthesia services. And considering everything builds on the past, that summation factor ultimately favors the MDA. Precisely! I cannot believe it. Someone finally understood what I was trying to say (and stated it far more succinctly than I could have). More background knowledge gives you a better, more thorough understanding of what you are currently studying. I remember, there were a few of my classmates in medical school who majored in disciplines other than biology. That means they did not have the physiology, endocrinology, cell biology courses, etc., that most of us had. They did not fare as well as the rest of us. They did well enough, but the courses in medical school were tougher for them. I think only 1 CRNA school offers the DOCTORATE DNAP at this time, the others award a MASTER'S. A CRNA is still the most fascinating and exciting role I could imagine working as. But I will know, or at least seek to know, my limitations. I don't mind having someone else around smarter than me, who may tell me I'm wrong because of something that I simply didn't have knowledge of. Think of it this way, the pt doesn't get hurt or die, and you learn something new that you will likely remember, move on... Perhaps my views will change after 10 yrs of being a CRNA, but hopefully this crap won't still be going back and forth and we can all just clam it and realize WE ALL have the opportunity to do some of the best, and most important work on the planet. QuestforWa, make no mistake about it. The doctors around you are not necessarily smarter. I have never assumed that any of the mid-levels with whom I work, nor the nurses caring for my patients on the floor, are somehow less intelligent than me. Less educated about medicine, yes. Less intelligent....who knows? Maybe they all have higher IQs than I do!

i was going to quote you but i just don't have the time. boy you're a tough one. inferiority complex? not nice...and where do you get this from? it seems to me that making mention of the fact that your training in the medicine of anesthesia is less than that of an anesthesiologist elicits a negative response from you. it's the truth, yet, it's a truth you don't want to be reminded of. and i am curious...when you deal with your colleagues or staff members and you do not agree with them do you ask them if they have an inferiority complex? my goodness, you're not even understanding what i'm saying, let alone agreeing with what i'm saying. the most obvious aspect of my whole argument here is that i am not belittling your profession. did i come to this forum and say, "crnas are incompetent pukes who should be cleaning bed-pans?" no. i came here saying essentially, "anesthesiologists have superior training in the area of medicine called anesthesiology." ok dr. holiday... less education... perhaps...lets compare the pathways just for fun... by your rule: you stated undergrad does not count. i think you stated it was a requirement. ok, let's see... undergrad is required for every graduate-level educational program. crnas are not in any way unique by having completed undergraduate degrees. you know this. so stop bringing your 4 years in college into the picture, because we all had to do it. the crna program is a doctorate level program which requires 36 months of education, lots of didactic and... like hell it's a "doctorate level" program. if it were a doctorate level program, you would be awarded the title of doctor. obviously, you are not. not only is not not a doctorate level program, it doesn't even meet the duration of a doctorate level program. with the exception of law school, there is no doctorate level program that is less than 4 years in duration. there is one exception to this: there is one dental school out of 50+ dental schools, to my knowledge, that has managed to squeeze 4 years-worth of dds training into a 3 year curriculum (by cutting out vacations and severely intensifying the program)....at least, that's what an omfs friend of mine who went there told me. every other dental school if 4 years (and miserably hard, from what my friends who are dentists tell me), optometry school is 4 years, podiatry school is 4 years, veterinary medicine school is 4 years, hell.....even chiropractic school is 4 years! but according to you, crna programs, which for some bizarre reason award a masters degree, are just 2.5 years in length. yet, you submit that crna programs are doctorate-level. here are last years residency case statistics for the graduating crna class: "residency"? that's rich! total cases - 640 asa iii and iv - 318 class v - 6 pediatric-50 emergencies 68 intracranial 8 intrathoracic 27 heart 10 obstetrical 41 invasive line insertions 10 regional administration 52 you being the expert, how do the above stats compare to those of an anesthesiologist program? i'm a head/neck surgeon, not an anesthesiologist. so obviously, i don't know the number of cases. i wish i did, however, it would have helped me make my argument. i would be absolutely shocked (and humbled) if those numbers surpassed the numbers and variety of cases handled by anesthesiology residents. now an rn can't get into crna school without 1-2 years of critical care experience...but according to your rule this experience counts for zero...it is a requirement. curious...i can't count icu time and i am wondering why you place no value on critical service. isn't this the place where you send all your post-op patients? aren't we the ones that keep them alive? but no credit...ok. mental note...icu unimportant to surgeons...ok. we covered this ground before, did we not? work experience is not the same as formal training. i'm not saying it counts for zero. what i am saying is that it is not something that should be considered as an equivalent to formal training. look, i know you like to add whatever experiences you have to your collection to make yourself appear closer to anesthesiologists in extent of training. but don't do it. it just makes your argument sound desparate. to continue... the crna program -- 3 years plus residency plus didactic for crna = 4 years for a total of 7.5 years of nursing education with 4 of those years focused on anesthesiology. oh but wait...as per your rule we can only count the 4 years. first, most crna programs are 2.5 years, are they not? where's all this other "didactic" and "residency" crap coming from? i looked up a few crna programs using google, and saw that they were 28 months in duration. anesthesiologist... undergrad in whatever you want. but since we're not counting undergrad, neither for crnas nor anesthesiologists, it doesn't matter what we study, now does it. 3 years med school + residency for total of 4 years. wow...8 years! three years in med school? funny, i spent four years in medical school. i must have been held back a year without being notified of it....just like my 120+ classmates. perhaps i should sue. how long is the program to become an anesthesiologist? is it 4 years? fours years of anesthesia training for the doctor. total of 12! wow! yes. twelve years. "wow" is a very good description of it. i believe the definition of anesthesiologist is: a medical doctor trained to administer anesthesia. and the definition of a crna or certified registered nurse anesthetist is: a registered nurse trained to administer anesthesia. don't you think you've oversimplified the job of an anesthesiologist just a tad? anesthesiologists are physician experts in critical care medicine and pain management. something crnas are not. so both disciplines trained in the same...anesthesia. see my comment above. now if we were comparing an md to an rn i'd say the md has the rn hands down when it comes to education in general. meaning the md spent way more time in school then the rn. but today dr. holiday we are talking about crna vs mda... thats a registered nurse trained to administer anesthesia vs. a medical doctor trained to administer anesthesia. you see, you are making the claim that the "anesthesia training" completed by a crna is the same as that completed by an anesthesiologist, and therefore, the only difference between crnas and anesthesiologists is the pre-requisite degree for their respective programs. you are wrong. like i said, crna programs are geared toward training nurses to provide anesthesia services. anesthesiology residencies are responsible for training doctors to become specialists in the science of anesthesia and critical care medicine. and by your rule... the rn undergrad does not count and neither does experience. nurses coming out of nursing school have very limited knowledge in medicine and i think you know this to be the case. your rn degree and pre-requisite "critical care" experience is certainly helpful, i'm sure, but it is not to be considered as formal training. it's just work experience that the crna programs want you to have so that they don't have to teach you how to "tie your shoes" during your 28-month program, so to speak. so by your rule... medical school does not count for the md...it is a requirement to be trained as an anesthesiologist. simply stated: the mds training is 4 years and allows him/her to administer anesthesia. the rns training is 4 years and allows him/her to administer anesthesia. i'm about ready to have a heart-attack here.... your problem is that you are viewing the roles of anesthesiologists and nurse-anesthetists as being identical. once again, they are not. anesthesiology is a specialty of medicine. it is not a trade like plumbing or auto mechanics. the anesthesiologist is a specialized physician....just like me. let me say it again: the anesthesiologist is a specialized physician. there is no such thing as being an anesthesiologist without having an m.d., d.o., or d.d.s. degree (yes, there are dentist anesthesiologists who work only with dentists). one must be a doctor or a nurse in order to be trained to administer anesthesia. now its not the nurse's fault the md chose to go to school for 12 years to do the same job and in all honesty i'd be upset too if that good looking crna standing next to me was getting paid the same $$. do you know that oral/maxillofacial surgeons (omfs) are trained to put patients under general anesthesia (i.e. intubate, administer ga agents like fentanyl, propofol, and halogenated ethers, as well as provide peri-operative management)? do you know how much anesthesia training omfss get during their 4 to 6 year residency? four to six months! they learn to do much of what crnas do in four to six months. what does this tell you? that administering anesthesia safely isn't that difficult. what else does this tell you? that the training of an anesthesiologist, whose residency is 48 months (including 12 months of internal medicine, which you crnas barely even touch) covers the science of anesthesia and critical care medicine in a level of detail that no crna program can touch. as far as the money goes, there's no comparison. crnas may get paid very well for compared to other nurses, but they don't come close to anesthesiologists. crna's are trained and paid to do the same job as an anesthesiologist. you're not practicing gereral medicine, diagnosing illness or giving orders to the floor nurse...tube and gas - 4 years period dr. holiday... obviously, you are ignorant of the training and skill of an anesthesiologist--to the point where you consider them to be essentially crnas with md degrees (which is probably why you refer to them as mdas). i don't know what else to tell you. it's your intent to continue your career in ignorance. the inferiority complex exists with the mds that are afraid to recognize educational pathways beyond their own. i mean really...if we start calling nurses doctor...heaven forbid...who would want to go to medical school? what are you talking about? we m.d.'s recognize d.o.'s as our peers, do we not? what you are expecting of us is that we recognize as equals health care providers who have had less training than we have had. but don't worry...i won't command that you call me doctor when i have dnp added to my name. you can go on calling me the nurse with the inferiority complex well, look at it this way: if you want to call yourself the "chief of surgery", i couldn't care less. but should you ever find yourself administering anesthesia for a patient of mine, don't forget whose license you are working under, and from who you will be taking orders.....should i be inclined to give them. i cannot believe i have wasted so much time arguing this topic with you. you obviously have made up your mind on the subject, and will continue to disregard every fact presented to you.

You must be absolutely right.....research means nothing, but since having an MD means everything plus the duration of education means even more at least when it is combined with an MD (if I understand what you are saying) then all MDs should be under the direct supervision of MD-PhDs because obviously those two degrees together must make better clinicians. I swear, it's like I'm talking to my two year-old. First off, the PhD is a research degree. It is not a degree like an M.D., D.D.S., D.O., D.P.M., etc. that provides training in clinical medicine (or one of its branches). Students in MD-PhD programs want both degrees because they want to conduct research, but have the ability to combine research with patient care. Anyways, did you not read what I said about the research to which you referred? Do you not comprehend the possibility that just because someone does research on a topic does not mean that his/her results do not necessarily produce accurate information? The very research to which you refer fails to take into account many things pertaining to the use of CRNAs in the delivery of anesthesia care, and because of it, neither I nor any of the anesthesiologists with whom I work regularly consider the research to be accurate in its conclusions--i.e. that CRNAs can do the jobs of anesthesiologists. Like I said, data can be cherry-picked to make any conclusion that you want. As the saying goes "anesthesiologists are the only MDs that work in a nursing profession". You know, I've heard lots of sayings. Such as "that's the way the ball bounces" or "it ain't over 'til the fat lady sings". I've even heard a saying that goes "If God didn't intend for us to eat animals, he wouldn't have made them out of meat." But I've never heard the saying that "anesthesiologists are the only MDs that work in a nursing profession." That must be one that's used only by nurses playing make-believe, pretending to be anesthesiologists. Good Luck in your profession DocHoliday and try not cough on any of your patients...:bowingpur Thanks! That's wonderful advice, doctor. (You don't mind if I call you "doctor", do you?)

Yes I agree... It is reasonable to think that perhaps Dr. Holiday's comments are based on a previous experience with an individual and not directed toward all CRNAs. Being very young and new to the profession perhaps he is frustrated or overwhelmed with his new position. No, my comments are a simple mentioning of the facts. CRNAs do not possess the extent, the breadth, nor the depth of training possessed by anesthesiologists. That is not an opinion. That is a fact. As far as my personal experiences go, you may be surprised to know that I have never had a bad experience with a CRNA (and I perform many surgeries). They have always met, and at times, surpassed my expectations. Because I perform a lot of surgery in OR settings, because my procedures always require some form of general anesthesia, and because I frequently deal with very ill patients, I am just fully cognizant of the educational and training differences between CRNA and anesthesiologists. I can't imagine that an MD with years of education and experience behind them would issue such a globalized statement and discredit an entire profession. Calling CRNAs less educated than anesthesiologists is not a globalized statement. It's a fact. If you consider this fact to be a "discredit" to your profession, then you're the one with the problem. This would be almost bad as someone posting "a 33 year old doctor is barely out of medical school and certainly does not have the maturity or enough real world experience to pass judgement on the world". That's an incredibly weak argument. First off, there's no such thing as "barely out of medical school". When we complete our four years of educational hell, we are doctors. The average age of completion is around 28 years of age. By the age of 33, we are either finished with our residencies or approaching the end. I finished medical school at 26, and completed my residency at 31, and my fellowship at 32. I am 33 years old now. Do I have all the experience of my older colleagues? Of course not. But the state in which I reside and the hospitals where I have privileges certainly think I have enough "real world" experience. My recommendation here is to pick and choose our battles. I have a long list of MDs that believe mid-level praticioneers are invaluable. I am not concerned with those who think otherwise. In time their confidence will be won over. Until that time of awakening we should do our best to support them regardless of condescending remarks. Your comment here reeks of an inferiority complex. Make no mistake about it: I think mid-levels are invaluable. I cannot imagine performing my work without them. You, however, seem to think that for physicians to view you as "invaluable", we have to view you as peers, i.e. as equal parties in the team of professionals charged with patient care. You expect us to think that you can serve in many ways as our surrogates. We don't think this. Rest assured, I treat the PAs and NPs (and yes, the CRNAs) with whom I work with the utmost respect. I am always welcoming of their input, and when they're wrong about something, I still treat them respectfully. But I never mistake them for my physician colleagues. That just seems to drive you up the wall. It is almost as if you wish that you could somehow be physicians without having to deal with those pesky little hassles called medical school and residency. You know, it just dawned on me; your use of the terms "CRNA" vs. "MDA". I wonder why you don't just refer to MDAs as "anesthesiologists" or "Anesth" or "Ans". I wonder if perhaps you use the letters "MD" in front of the "A" in order to make a distinction between "physician anesthesiologists" and what you apparently perceive to be "nurse anesthesiologists".