Bluebolt

In the last two years, I don't think I've ever moved anything on a regular basis other than the head/neck. If I'm trying to be an overachiever when the scrub techs and circulators grab both sides of the torso and lower body I'll stick my hands under the shoulders to move from the OR table to the stretcher. I try to be a team player.

It will not be fully automated. It will always require a human component to at least monitor and assess the machines and take over in case of emergencies or electrical shut down. Would you go into surgery knowing that if there is a power outage or a plug pulled you're definitely going to die? I didn't think so, neither would anyone else in a first world country. In probably 30-40 years when the technology has advanced to a level that could potentially change the practice model we use today where machines are practically doing anesthesia, you will still be needed. At that point, I plan to incorporate cyborg technology into my person and assimilate with the machines while keeping my own cognition. The ultimate anesthesia expert with rapid recall of all medications/dosages/pathophys and machine-like precision of skills. Thank you for coming to my TED talk.

Wtb, where have you been!? I was starting to get worried you deactivated your account. You always bring clarity and reason to a discussion that is filled with anecdotes and extreme bias. Good to see you back.

I haven't been there personally but I have heard of an all CRNA group that does CABG and valves. Where I did my cardiac training the CRNAs ran the cases and there was a physician anesthesiologist available for backup if needed. The MD/DO would come in intermittently to check the TEE and assess the valve function. One of the CRNA only sites I rotated through during my third year did vascular cases like CEA's and AAA repair. I got the opportunity to learn on those cases and manage them with the CRNAs backup if needed. Twinsmom788, you continue to have very strong opinions about CRNAs and their capabilities for an RN with no training in anesthesia. It's always interesting to see your hot take on a subject though.

Your hyperbole and melodrama have made this an engaging conversation. I've enjoyed our discussion and wish you luck in your future endeavors.

I'm guessing you're an MS2 or MS3 from the passionate debate in favor of the robust clinical skill of medical students. I'm afraid any nurse working in the hospital when MS4's graduate and become residents know just how little clinical application ability is there in the beginning. I'm not saying medical school is useless or med students are bumbling fools in the clinical arena so please lower your blood pressure. Although, If you believe that a medical student has the same expectations and performance of a third-year SRNA you're wildly delusional. In fact, on my first rotation as a second-year student, I had more responsibilities and expectations than the MS4 rotating with us. She at least had the sense to admit that and make polite conversation. I did a med school internship and chose to do a CRNA DNP instead because I could see the changing of the tides in healthcare. As you say, physician anesthesiologists will make $400,000 a year where a CRNA may make $200,000 a year. The more economical option between two anesthesia providers who can perform the same role is exactly why the future is so bright for CRNAs.

I've dated residents, and have family who are physicians, let's not kid here. The first two years of medical school are almost entirely didactic while the third and fourth year is much akin to advanced shadowing experience quickly rotating through many different specialties to get a taste of all. I have done anesthesia rotations where MS4s are doing an elective rotation there. We talk and get along and I try to help them out through the nerves and jitters. Most will admit they took the elective rotation for the easy schedule and not really be expected to know much or be pimped on anesthesia. They also confirm what you mention that they learn next to nothing that relates to anesthesia in med school. You also rightly note that the first year of anesthesia residency is not anesthesia related but teaching you as an intern how to provide basic medical care to patients under heavy supervision and guidance. The next three years of residency are when they spend their time performing anesthesia in a graduated amount as they become more experienced. I have personally met physician anesthesiologists who have admitted to me their residency did not give them adequate peripheral nerve block experience and they would call on their colleague to assist them when they needed to perform one in practice. It should also be noted that it is a requirement in curriculum of CRNA programs and in clinical practice that you have full didactic knowledge of regional anesthesia and have performed it numerous times in clinical situations. Recently, our board certifications to practice have increased the amount of material on PNBs and Neuraxial so it has a much heavier focus in school than decades past. Last note, it is a requirement that you cover cardiac anesthesia (CABG, TEE, Valve replacement) didactically but also that you do a cardiac rotation where you take these types of cases.

Many CRNA programs do require organic chemistry and physics, along with general chemistry, microbiology, anatomy and physiology 1&2, etc. I also did take a gross dissection course in undergrad. I'm sure it wasn't the same rigor as medical school but it was good exposure. Once I started my doctorate in nurse anesthesia we did take very rigorous courses in A&P and gross dissection that did last a year. We also took organic chemistry at the graduate level. I understand you're a proud mother of your daughter's accomplishments, as you should be, but it leaves you with a stark bias. It also isn't a strong argument that you should speak as an authority on CRNAs education and capabilities because you have a BSN and maybe observed some of them work.

From speaking to many of them I gather they like the work/life balance of anesthesia, the lack of having to do a clinic, no continual followup with noncompliant patients, no rounding in the hospital, and the procedures and challenges anesthesia presents. There is also a lot of financial incentive for CRNAs and physician anesthesiologists in anesthesia, especially for physician anesthesiologists.

Day one of your CRNA training you are being prepared to be an independent anesthesia provider. If you manage to get to graduation and still think you need another anesthesia provider to think through hard situations for you, your program has seriously failed you.

I don't want to derail the conversation away from the OP. In short, I think it's multifactoral from my personal experience in the nursing field and anesthesia field. CRNAs do not round often on their patients after surgery and when they do post anesthesia evals it's quick without much interaction with the nursing staff. They spend most of their career behind closed doors in the OR behind a drape moving levers, knobs and pushing drugs to provide a smooth anesthetic for the patient. Most nurses never even see CRNAs do their job unless they are circulators. Sadly, even some circulators don't have an accurate grasp on what the CRNA is doing or thinking, from what I've gathered interacting with some. Being an anesthesia provider is like being an airline pilot, it may seem like we're calm and just silently changing settings or giving IV meds but the reality is we're averting potential bad outcomes thinking three steps ahead. As you can see from this post in the CRNA specialty tab and no CRNAs or even SRNAs are bothering to engage, CRNAs have mostly given up on educating other nurses about the field. I suppose we don't ask pathologists, chiropractors, orthodontists, and optometrists to come on here and educate on their specialty and CRNAs don't feel like taking the time to do it either. I was active on this forum when I was a nursing student, then an ICU nurse, and throughout my anesthesia training, so I still try to engage. I'm not so far removed from my years in the ICU to think it's a lost cause to have scholarly constructive discussion with the nursing community at large. That's the reason I posted this discussion topic in the first place, to have respectful discourse. It's fine to have strong opinions and make grand statements here, but it should be backed up with data to support it.

I apologize if it comes off as condescending. The first week of our doctoral training we were constantly reprimanded for making broad statements, like denigrating an entire profession, without hard evidence or statistics. I was constantly reminded in my weekly research papers or even in lecture that anecdotes and opinions carry as much weight as the air it's spoken on. After three years it has become second nature for me to disregard discussion that has no research, evidence, or merit beyond a single persons perspective. It may be interesting as far as stimulating you to investigate if this perspective is shared with more than one person, but even on here a sample size of 50-100 people would not be statistically significant. I know this is the internet and I could be speaking to a 19 year old at a junior college but let's strive to be better. If we have strong opinions like "CRNAs have a fraction of training, CRNAs will kill patients if a physician isn't directing them, CRNAs are only good for basic healthy cases, MS3's can perform anesthesia safely" you need to support this with peer reviewed research and statistics. Otherwise, it's as relevant as me saying the sky is green. As someone who has completed three years of anesthesia training and am graduating, I've been in the research, I've provided anesthesia for hundreds of cases, thousands of clinical hours, many complex case types and procedures, and I already have an opinion on CRNAs practice, capability and safety. You won't see me making those definitive opinions here though, unless I supply the research and statistics behind it.

I'll try to make this a little more clear for you because admittedly it can get convoluted. During my few years of anesthesia training, I've done rotations at many different clinical sites. Some of the sites are considered medical direction which is like the situation you described where an MD may do the preop assessment and 4 CRNAs are working connected to that MD. These 4 different CRNAs will show up to preop, give their preop cocktail of choice then take the patient back to the OR. The MD is supposed to show up at this point to assist in induction and intubation, then leave and go about doing other tasks to help workflow in surgery move smoother. They are also supposed to show back up at the end of surgery and be present for removing of the breathing device and waking up of the patient. In order to bill Medicare/Medicaid for their services, they must document they do this on every case for all 4 different CRNAs every day all the time. Research has shown that there is a large percentage of time that they are not present or involved but they bill like they were. That's the issue the AANA is addressing in the original post. I only rotated at 1 site that still does this billing model. What many other groups have changed to is a medical supervision model which is more of a collaborative environment where CRNAs and MDs may run their own cases. They may do their own preop or help each other if they get spare time. Everyone works to the top of their license and you don't have to be in the room when you go to sleep or wake up. The CRNAs bill insurance as an independent provider, etc. This has been 80% of the facilities I've rotated at. Then you have CRNA only practices where they all work to the top of their license, manage the business side of anesthesia, take a decent amount of call, and have ownership over the group. I rotated through a couple of these locations. I hope that clears up some of the working environments and billing models that exist in anesthesia.

I really appreciate your comment. It's input like this that lets the CRNA community understand how much education about the specialty is needed even within the nursing community. You have a great deal of misinformation and opinions that seem to be based on ignorance. It's okay because it's really our failing for not informing and engaging with the nursing community so they have a better grasp on CRNAs and their practice. I worked in the ICU for years and actively sought out information about CRNAs and was still shocked how much I didn't know or what I knew that was skewed when I began training. Thank you so much for your input!

You're right but I don't want this to become a topic of "us versus them". That isn't what the purpose of the AANA statement or my posting here is about. Mutual respect with our physician colleagues is important currently and going forward as anesthesia progresses and grows. The AANA statement is not really saying anything new that they haven't supported before or stated before, just simply using more direct wording. The idea is to reveal that CRNAs have been experts in anesthesia for a long time and as you mentioned, are the original anesthesia provider and the oldest advanced practice nursing specialty. As my original post mentioned they bring up old billing models and delivery of care that is not the most cost-effective, and very possibly fraudulent. Many practices across the nation have been transitioning out of this model and into a more collaborative independent model that uses CRNAs to their full scope of training and licensure. Their statement is supporting this transition. The only thing that is slightly more highlighted in recent statements is the fairly new descriptor, nurse anesthesiologist. The voting members of the AANA have stated they feel this term is more in line with the anesthesia expert they feel CRNAs represent. They have also stated that physicians were also called anesthetists until many decades ago they stated they were experts and would be called anesthesiologists instead. As an SRNA I am not a voting member on this topic and have no opinion.

I appreciate your input on the topic. It's common for those not in the anesthesia community to get this confused. It is very very rare to find a group where MDs and DOs provide the anesthesia themselves. Almost always even if you speak to a physician in preop and they say they are "providing" your anesthesia today, it will actually be a CRNA who does your anesthetic. The CRNA often comes in right as it's time to roll back to the OR and gives Versed as a part of their anesthetic preop meds, which has an amnestic effect and many patients never remember meeting them. This is the billing model that physicians prefer and what I referred to above as a 4:1 ratio.

Before we begin a discussion on the topic you should probably follow this link to the AANA's original statement. Firstly, I have to disclose that I am in my third year of nurse anesthesia training preparing for graduation, so I am not a board certified CRNA yet. Anything I say is coming from the perspective of a new generation of CRNA DNP training which I've noted can be slightly different from those of older generations. I am also the elected political representative of my class throughout our program so I do stay more engaged and informed than some other anesthesia trainees. Last disclosure, I do serve the AANA and work on a committee that serves the board of directors. Now, to understand where this new bold statement from the AANA came from I think it's necessary to understand it is in response to the ASA's statement about the Anesthesia Care Team last fall. Their statement unabashedly self-aggrandizes themselves and downplays CRNAs actual role as experts and independent anesthesia providers. In fact, they use wording that implies better education and training from their own assistants (AAs) than nurse anesthetists who has been providing safe competent anesthesia since the civil war. Although, most CRNAs don't blame them for making a political statement like this promoting themselves and downplaying their competitors in the marketplace. That is the duty of a professional organization, to promote that organization. Anesthesia has been aggressively political since the early 1900s when physicians decided to start learning anesthesia and tried to make it illegal in California for a nurse anesthetist to continue practicing anesthesia. Who wants competitors if you think you can eliminate them, it just makes business sense. After the political statement made last October by the ASA large amounts of CRNAs were outraged and demanded an immediate defending response from the AANA. The AANA is always careful and intentional in what it does, so they created a task force of influential and level headed CRNAs who would investigate the issue and come up with a diplomatic response. They spent 6 months discussing this and coming up with the response you are now reading. This statement was intentional and well thought out. It is supported and celebrated by a huge majority of CRNAs/SRNAs judging from responses in person and in private CRNA forums consisting of tens of thousands of CRNAs. It's disconcerting that I have seen some negative comments online by people who aren't physicians. You would expect many physicians to react negatively to a non-physician provider talking about their education, training, and similar patient outcomes but it is odd to see some others ill-informed negativity. The biggest confusing issue I see people have is that in the AANA's statement that is in response to the ASA's care team statement is that billing methods are often fraudulent. What many may not understand is that in a medical direction billing model (which is what the ASA is wanting everywhere) involves meeting 7 TEFRA requirements to bill for CMS. These requirements are very often not met even when physicians bill in medical direction, which is Medicare fraud. This is not just anecdotal. The ASA produced research they performed themselves that was published recognizing that a huge number of medical direction practices are not meeting the 7 TEFRA requirements. Medical direction benefits the physician because they can bill for 4 different cases at once while they are not providing the anesthesia but 4 different CRNAs are performing the anesthesia. You can see why they would want this to be a standard delivery method of anesthesia. Even when their own research shows they are fraudulently billing in many places they continue to push this model. This model is oftentimes the most restrictive and oppressive to CRNAs who choose to work with that anesthesia group. It is also one of the more costly models for hospitals to sustain, so it's not economically responsible or sustainable for many facilities. CRNAs mention these issues with medical direction because it supports the movement nationwide for the collaborative model of anesthesia care. This model requires that both CRNAs and MDAs be independent full practice providers who work together on a team. They are equal partners and practice under their own license to provide safe high-quality anesthesia to their patients. In this model, there are no 7 TEFRA regulations so Medicare fraud is not an issue. The economic reason some in anesthesia will not like this anesthesia delivery model is that you can not bill for services of 4 CRNAs at once providing anesthesia. Each provider can only bill for their own anesthesia for a single case. It would do away with someone sitting in the break room drinking coffee while 4 other providers are working and earning you profit. You can see why certain people would not want this to happen. I just wanted to clear that portion up about the AANA's statement so it had some context and people who are not in the anesthesia realm understand where that came from. Those of us in anesthesia are just so used to that issue I think we forget others are not informed about it. What do you guys think about the new statement?

I'm not sure what part of the country you're working in or the types of practices but this is opposite to the experience I've had so far. A year before graduation we had groups coming to campus, buying us meals, giving us gifts, paying for flights and hotels to interview at their practice, offering sign-on bonuses, incentive benefits packages, etc. One of the groups I interviewed with offered a partnership track, another mentioned that they would be soon looking for leadership CRNAs during my interview. All the positions offered salaries between $200-$300K annually. This includes call of course, which is the nature of anesthesia. I settled on a location I liked very much in California. As for politics, you're very right that is a very political specialty. That's been going on for a century and will not change very soon. Our first semester of school we had an entire course designed to educate us on the history of nurse anesthesia, the competitors in the market, and the politics. By the time you reach the third year of the program and you're ready to interview for jobs you should be able to sniff out a politically toxic practice from a mile away. My method was always asking if CRNAs did their own blocks, lines, PACU management orders, preops, etc. If there was any hint of a no in that list I thanked them for their time and moved on. Also, any use of professional slurs like midlevel, I'm out. As for being bored with anesthesia, I can't speak too much to that because I've only been doing it a couple of years. For those anesthesia providers with more experience, I've been told that mixing things up makes it less boring. Work some OB call into your life, introduce some healthy peds back into practice, try learning more complex or new PNBs, look into some ERAS protocols and see if your facilities keeping up with the newest research, try your hand at opioid-free anesthesia, investigate outpatient ketamine clinics, do 1099 at an endo center, see if you like doing sedation for dental clinics. I may one day go be a professor, which is one of the benefits of the DNP. So continue your education and it will increase your flexibility with academia and non-clinical roles. Get active with the AANA, attend national meetings, join a committee. All of these things will help spice up the day to day mundane that seems to be bringing you down. As for if you should have gone a different path, that is very dependent on each person. Although, I would never advise someone to go to med school unless they were wanting to do a surgical specialty. I can't even count how many residents/physicians I've heard say they wish they had done business or CRNA instead. The grass is always greener on the other side, except it never truly is.

Give it 10 years. Shoulda matched into surgery!

In August there is a vote being brought forth by CRNAs to officially change the national association's name to the American Association of Nurse Anesthesiologists. Apparently, through an AANA task force, it was discovered that "Anesthetist" nor "Anesthesiologist" is a legal title and cannot be copyrighted. Legal counsel advised that both were merely descriptors. I suppose that is why the ASA officially changed their stance to referring to themselves as physician anesthesiologists instead of just anesthesiologists. It's also probably why dentists who have done some training in anesthesia refer to themselves as dental anesthesiologists. I understand people have a great deal of emotional and nostalgic reactions to certain words or phrases. I'm interested in seeing how the world of anesthesia progresses over the next few decades.

You should specify when you say anesthesiologist if you are referring to dental anesthesiologists, nurse anesthesiologists, or physician anesthesiologists. CRNAs have great working relationships with all their fellow colleagues in anesthesia.

I have met CRNAs who have done pain management training and do practice it independent of physician anesthesiologists. While this is possible it is an uphill battle and some states can make this type of practice very difficult for CRNAs. There are all kinds of legislative loopholes and old laws on the books that can be a barrier to practice for CRNAs. They told me that most recently they had a legislative battle defending their scope of practice to treat acute pain but was told they aren't trained in CRNA school for chronic pain management. I've talked to some program directors who have stated they are implementing more of a focus on pain management and the pathophysiology and blocks required for that.

I understand your perspective, Offlabel. I've heard so many convincing viewpoints on both sides of the debate about this hot topic. I'll leave my personal opinion out of it until after my upcoming graduation.

Wow, Offlabel, you surprise me. I would have never taken you for the type to support this new movement. Big changes seem to be on the immediate horizon.

I wouldn't have been anything else. The hardest thing I've ever done but also the most rewarding.