Scope of Practice

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How is scope of practice defined for CRNAs? Is it based on training in CRNA school? Based on common usage of techniques by CRNAs?

No...I don't think I side stepped the question. As long as it is natural extension of anesthesia I do not believe it is stepping into the legal definition of the "practice of medicine". What you are discussing is pure skill sets learned in residency. Where do you draw the line for physicians or are they allowed to do everything soley because they went to medical school?

Nursing and medicine continue to evolve daily. Things that nurses do today would only have been done by physicians 30-40 years ago. Do you think starting IVs should only be done by physicians...probably not since as an AA you probably start several a day. I have worked with nurses that still remember not being allowed to start IVs, because only physicians were allowed to do them when they 1st started nursing. It all is just a natural evolution of skills as more complicated skill sets evolve physicians will naturally lead the way in most of them, and nurses will take over other skill sets that only physicians used to do.

If you removed the money factor and egos (some on both sides) do you really think that pain management would be any real issue? There is no research, that I know of, that states that CRNAs are inferior to MDAs in pain management, so why not allow them to practice pain management if not for physician egos and loss of income issues?

Sidestepping again - that's why I gave the example that CNM's don't do C-Sections.

So you see no difference between an MD who has a fellowship in pain management and a CRNA that's attended a weekend or at best a week-long NAPES course? Politics and money aside, it's the patient that is clearly short-changed in the end.

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Specializes in ICU, currently in Anesthesia School.
Sidestepping again - that's why I gave the example that CNM's don't do C-Sections.

So you see no difference between an MD who has a fellowship in pain management and a CRNA that's attended a weekend or at best a week-long NAPES course? Politics and money aside, it's the patient that is clearly short-changed in the end.

I see the difference in a Pain Fellow versus any other provider, assuming the completion of a fellowship in an accredited program (relatively few out there, No?). However the fallacy in the argument is as follows: Even within the physician's world, Pain Fellows are not the only ones hanging a shingle out for "pain management".

"Pain management" is currently the domain of many disciplines. I am sure that PMR, Neurology, Physical Therapists, Chiropractic doctors, interventional radiologists and anesthesia providers would probably argue with you that pain fellows are the only ones who can manage pain appropriately. All are trained and educated to manage pain. I am partial to anesthesia providers, whether MD or CRNA, for obvious reasons- but I see the other providers point.

Your comparison of CNM's inability to do C-sections does not hold due to the fact that CNM's are not educated or trained to perform the procedure. All anesthesia providers are trained and educated in pharmacologic pain management, and the rational/indications for usage of the techniques. A skill such as needle placement or intrathecal pump placement can be learned easily.

As for Scope of practice for any profession, it is defined by 3 things:

1. Professional Association (ASA for the docs and AA's, AANA for the CRNA's)- Usually worded in all sides to prevent limitations to practice. (note- Could jab jwk here- will take the high road.)

2. State legislatures- Medical boards for the docs and AA's, Nursing boards for the NP's/CRNA's ( Usually worded to maximally benefit the population of the state and protect citizenry)

3.)Institutional/Individual Priviledging- Defines the exact procedures that each provider may perform. Here is where the "scope" as most people think about it is defined. (This is where even the docs get limitations. Example- An anesthesiologist may be priviledged to place a central line, but not to place a chest tube if a pneumo is created. Similarly- so that I am not accused of picking on anyone- A general surgeon would not be allowed to perform a craniotomy. And a corporate tax lawyer would not typically be allowed to represent someone for a death penalty case.)

So even though my professional scope will be the practice of all things nurse anesthesia, and a state approves that scope, a facility may restrict my practice by institutional priviledges. So legally-As there has been many a court precedent set- as long as I am performing the anesthesia it is the practice of nursing and regulated soley by the board of nursing. I will only say this about the LA court ruling- See deepz's post.

Hoping this clarifies the issues a little.

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Specializes in Anesthesia.
Sidestepping again - that's why I gave the example that CNM's don't do C-Sections.

So you see no difference between an MD who has a fellowship in pain management and a CRNA that's attended a weekend or at best a week-long NAPES course? Politics and money aside, it's the patient that is clearly short-changed in the end.

Again your opinion only...provide the research to support your argument and I will agree totally with you otherwise we will continue to disagree.

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Again your opinion only...provide the research to support your argument and I will agree totally with you otherwise we will continue to disagree.

I need research to show that CNM's don't do C-Sections?

And I asked a question - I haven't raised an argument that I need to support. The question, one more time, is at what point does something cross the line and become the practice of medicine? Or in your opinion does no such line exist, for anesthesia or otherwise?

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Specializes in Anesthesia.
Politics and money aside, it's the patient that is clearly short-changed in the end.

"And I asked a question - I haven't raised an argument that I need to support. The question, one more time, is at what point does something cross the line and become the practice of medicine? Or in your opinion does no such line exist, for anesthesia or otherwise? "

This looks like an opinionated argument that needs to be proven with research.

I think I have answered the question a couple of times over.

"As long as it is natural extension of anesthesia I do not believe it is stepping into the legal definition of the "practice of medicine". "

Now if you still need an example to clarify that statement here you go: If a CRNA starts doing brain surgery then they are practicing medicine, because it clearly is not a natural extension of their education &/or training in anesthesia.

When you want to debate some actual facts/research then we can continue this discussion otherwise saying the same things over and over is fruitless. You obsiviously identify with AA/MDAs point of view just as I identify with the AANA/CRNA point of view.

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Nowhere in this country are CNM's allowed to do c-sections and that won't change anytime soon.

The Louisiana decision is a major blow. It's not one judge. It went all the way to the Louisiana Supreme Court and they decided that pain management is medicine. If CRNA's want to legally do pain management, they have to change the practice acts. That's like saying CNM's just need to convince the state legislatures to let them do c-sections. Don't hold your breath.

For the time being, CRNA's who do pain basically are doing it under the radar. They don't want to raise their profile too much unless they want the same thing that happened in Louisiana to happen in their state -- a formal ban. In law, there's a principle that typically once one state sets a precedent most others follow.

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If you removed the money factor and egos (some on both sides) do you really think that pain management would be any real issue? There is no research, that I know of, that states that CRNAs are inferior to MDAs in pain management, so why not allow them to practice pain management if not for physician egos and loss of income issues?

Let me throw that right back in your face. Why are CRNAs fighting against allowing AAs in a bunch of states since there is no evidence that they are inferior providers of anesthesia?

The ego and money issues work both ways, my friend.

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Let me throw that right back in your face. Why are CRNAs fighting against allowing AAs in a bunch of states since there is no evidence that they are inferior providers of anesthesia?

The ego and money issues work both ways, my friend.

Yes it does!:yeah:

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Another point. It doesn't matter if someone thinks that CRNA's can adequately trained in a weekend to do pain. What matters is what the courts and practice acts say. So it's pointless here to argue that CRNA can do pain. The people you need to convince are the states to amend their practice acts. But what justification can CRNA's provide? That I took a weekend course for it? While on the other side, the physicians say that pain is a 1-2 year fellowship. It's a huge uphill battle.

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Specializes in ER/ICU, CCRN, SRNA (class of 2010).
Let me throw that right back in your face. Why are CRNAs fighting against allowing AAs in a bunch of states since there is no evidence that they are inferior providers of anesthesia?

The ego and money issues work both ways, my friend.

I hear what your saying pal, but I applaud the AANA for stepping in and making any effort to stop AA practice. The same way that the Nursing assoc. should have stepped in to stop PA practice in it's infancy. Unfortunately for NPs they were asleep behind the wheel. Well the AANA is not!!!!! We will not allow the AMA or A$A to back door in another profession to maintain there strangle hold on health care.

Smiley

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scope of practice for CRNA's is determined by state board of nursing, not medical boards. If the ASA or medical boards would like me to define their practice then they may define mine, until then thier opinion is not wanted or appreciated.

As for AA's I am sure they are fine providers just exploited by the ASA, hell a completly dependent provider (by law not ability) is a dream just imagine people who have to do your work and you get to bill for "direction" give oxygen, or "supervision. OHHHH SWEEEEET.

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I need research to show that CNM's don't do C-Sections?

And I asked a question - I haven't raised an argument that I need to support. The question, one more time, is at what point does something cross the line and become the practice of medicine? Or in your opinion does no such line exist, for anesthesia or otherwise?

This question cannot be answered in this type of forum for the basic fact of origin of differing definitions.

AANA's argument is based on the historic origins in the US of anesthesia providers, its rural provider percentages, and that anesthesia does not heal per se or treat an existing disease (this does not include pain patients/clinics - where anesthetist are rarely found) - it deals with management of existing states and returning the patient to the condition which they were received in.

The ASA point is that anesthesia is a field of critical care and pain medicine, which does include treating existing pathologic states in addition to the end of the above sentence.

But both will agree (grudgingly) that in appearance and function (& outcomes) - one private practice CRNA compared to a MDA doing a lap chole - is the same...so ...there is and there isnt a difference in function or.... as you asked does it cross the line. No I am not going to discuss the ACT. Nor will I argue the outcome studies

The lines are muddied and will continue to be so- matters who you ask....the ASA has long pointed out that in addition to the above the are obvious differences in education which is expressed in level of diagnosis and treatment to augment their practice....CRNAs will tell you that the training in pure anesthesia sciences are equal. Diagnosis and treatment experience be damned - I can say that ICU experience is a varied substitution for ones ability for differential diagnosis - that CRNAs can obtain this skill but with a great degree of effort and study.

So you decide..you cannot ask a CRNA or a MDA this question - we are too wired to answer in a specific fashion...

thanks

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