Unsupervised anesthesia care by a nurse anesthetist is a threat to patient safety

No matter how quickly you tried to switch the television channel lately, you probably couldn’t escape the trial of Dr. Conrad Murray or avoid hearing about propofol, an anesthesia drug that can be fatally easy to use.

What you may not have heard is that the American people just dodged a serious threat to their anesthesia care, and most don’t know how near a miss it was.

The Centers for Medicare and Medicaid Services (CMS) recently issued new rules concerning the conditions of participation in Medicare and Medicaid for hospitals and health care providers.  Despite intense pressure, CMS sensibly left in place the rule that requires nurse anesthetists to be supervised by physicians.  We should all be thankful, and stay on guard in case anyone tries to change that rule again.

The new rules are open for comment until mid-December, and lobbyists no doubt will continue to argue that all anesthetics can “just as easily” be given by nurse anesthetists alone.  This is a bad idea, and CMS should stand firmly against it.

Here’s the background.  This year, the Obama administration announced a plan to reform health care regulations that were unnecessary in its view.  In particular, the administration said, the “use of advanced practice nurse practitioners and physician’s assistants in lieu of higher-paid physicians could provide immediate savings to hospitals”.  In the new rules, CMS reasonably proposes to remove barriers to the work of physician extenders, for example by not making them seek out a physician to co-sign every order.

But if lobbying efforts had succeeded, nurse anesthetists—alone among other mid-level providers—would be allowed to practice without any supervision at all.  Hoping to make anesthesia services more profitable for hospitals and insurers, lobbyists purposely blur the differences between the education of physicians and nurses. They want to get rid of the cost-effective anesthesia care team model, where nurse anesthetists or anesthesiologist assistants work under physician direction.

Mid-level providers on every team are essential to health care.  When patients go to a primary care doctor’s office, they are likely to see a nurse practitioner or a physician’s assistant who can treat routine complaints, manage chronic illnesses like high blood pressure, and write prescriptions under the doctor’s authority.  If you need surgery, a physician’s assistant may assist your surgeon in the operating room, and a nurse anesthetist may look after you under the supervision of your anesthesiologist.  They’re working as part of the team, not replacing the physicians.

Dr. Jane Fitch, recently elected First Vice President of the American Society of Anesthesiologists, began her career as a nurse anesthetist with a master’s degree.  Troubled by her limited knowledge compared to the physicians she worked with, she soon went back for eight more years of education—completing medical school, residency, and then a fellowship in cardiac anesthesiology.  While she was a nurse anesthetist, “I didn’t know how much I didn’t know,” Dr. Fitch says.

Military families may be surprised to learn that if you become a patient in a U.S. military hospital (which isn’t bound by CMS rules), you may receive anesthesia from a nurse anesthetist who isn’t required to work with an anesthesiologist.  This rule applies whether the patient is a healthy civilian having a minor procedure, or a grievously wounded soldier needing major surgery.  The anesthesiologist may be called in to rescue the patient only when complications have already occurred.  “Suddenly it’s my case, and my problem,” says a Navy anesthesiologist in frustration.

President Clinton (whose mother was a nurse anesthetist) signed into law in 2001 a rule that permits states to “opt out” of the CMS requirement for nurse anesthetists to be supervised by a physician.  Sixteen states—unfortunately including my own state of California—have adopted this rule to date.  While it was originally intended to help rural areas improve access to care, the “opt out” rule supports any hospital that seeks to cut costs by allowing nurse anesthetists to work alone.

By signing the “opt out” rule, President Clinton apparently meant that anesthesia care by a nurse anesthetist working without supervision is all right for you and for other people.  When Clinton himself needed heart surgery, a physician specializing in cardiac anesthesiology headed his anesthesia team.  The same was true of Governor Schwarzenegger, who signed the letter in 2009 allowing the state of California to opt out of physician supervision of nurse anesthetists.  When he needed surgery, a board-certified anesthesiologist personally provided his anesthesia from start to finish.

Now there’s a new threat to patient safety.  Section 2706 of President Obama’s Patient Protection and Affordable Health Care Act (PPACA) prohibits discrimination by insurance companies against health care providers as long as they are acting within the scope of their licenses.

It sounds innocuous.  But this “non-discrimination” clause opens the door for non-physicians—like nurse anesthetists or chiropractors—to open clinics without physician oversight and bill insurers directly for anesthesia nerve blocks, epidurals, and other complex pain management procedures.  These techniques benefit many chronic pain patients, but they carry the risk of life-threatening complications.  Under the misguided logic of this law, I could deliver babies or take out gallbladders because I’m a licensed doctor, even though I’m not an obstetrician or a surgeon.

The Obama administration expresses concern about the “impending shortage” of physicians as a reason to allow more latitude to advanced practice nurses. Certainly, public health nurses in the community don’t need immediate physician supervision to deliver care safely within their scope of practice.  But anesthesia and surgery always carry the risk of sudden complications requiring physician intervention, whether in a hospital or an outpatient surgery center.

If we cut out physician involvement in order to make anesthesia cheaper, we’re kidding ourselves to think that quality and safety won’t suffer. The American people deserve better.

Karen S. Sibert is an Associate Professor of Anesthesiology, Cedars-Sinai Medical Center.

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  • http://www.facebook.com/people/Janice-Boughton/562084033 Janice Boughton

    In our “opt out” state, nurse anesthetists do work without anesthesiologist oversight. We are a small rural hospital, and they do a fine job. Cases that are more complex and require an anesthesiologist need to be shipped out, as do complex surgical cases and cardiology that requires intervention. It is true that CNAs don’t have the same level of training as MD anesthesiogists, but internists also don’t have the same level of training in cardiology as cardiologists and we treat heart disease. There will always be health care providers of varying skill levels practicing medicine, some of the variability is due to training, some due to talent, some due to experience. I agree that cost issues may adversely affect care as we attempt to reduce spending, and we want to avoid that. As far as CNAs being alone among midlevel providers in being able to practice without supervision, that is not true. Nurse practitioners in this state are also independent of MDs. When they see patients for routine problems, there is a risk that something more rare will be missed due to training, which I do see. Still, much good medicine is practiced by our independent primary care NPs and they certainly allow faster access. Better to be seen today with your pneumonia by a NP than wait until next month to see a MD.

    • Anonymous

      While I agree with the overall sentiment of your post and respect all midlevel providers as an intergral part of the team some of your examples are flawed.  First, yes internists routinely treat heart disease, and they of course do this without requiring supervision.  However the internist is also a physician and isn’t trying to work towards doing caths either.  They know what patients need to be referred to a cardiologist and do as such.  You also describe NPs as being allowed to act independently and treat routine issues which is also true in a number of states.  However the issue being discussed in the article is independent anesthetic delivery by midlevel providers to all patients, CRNAs aren’t offering to perform only the “routine” procedures, they are looking for parity and the government is considering giving it to them in the name of cost effectiveness.  What’s next allowing a PA who has worked under a Cardiologist for 1 year being allowed to jump into the cath lab and treat patients independently?

    • Luke .

      This is a good and honest post.

  • Leslie White

    I’d take this point of view much more seriously if it wasn’t offered up by an anesthesiologist. It has a “conflict of interest feel.”

    • http://pulse.yahoo.com/_XK2MFFDKGVWZAIWA4WLQHC5GEA Sean

      Duh….  MDA alone in room doing own case.  Bills 100% of the anesthesia case.   ACT “safest model” 4 rooms to 1 MDA supervising… Bills 50% to the CRNA and 50% to the MDA  …. PER ROOM…. yeah, that comes out to 200% for the “safest” model…. right.

  • http://twitter.com/mmacfn1 Mike MacKinnon

    Evidence?

    Oh that is right, there is none after over 100 years of Nurse Anesthetists working independent of anesthesiologists.

    I cannot take seriously the arguments of “safety” without a single shred of evidence from someone who is paid 3-4X the amount as a Nurse Anesthetist is for the same job. 

    As they like to say in Texas, ‘that dog just dont hunt.’

    • http://pulse.yahoo.com/_T4D4DSUXB4YECMFJTQ7MM227ZQ Sherlock

      A perfectly well-controlled, well-powered study would be logistically quite difficult and morally questionable. But to state that there isn’t a single shred of evidence is wrong. For a number of studies that support this, read Mark Warner’s June 1996 publication in Anesthesia and Analgesia supporting the Anesthesia Care Team as the safest model. He cites a few.

      There are multiple reasons that evidence regarding this (on both sides of the issue) isn’t all the highest quality, but don’t assert that none exists at all.

      • http://twitter.com/mmacfn1 Mike MacKinnon

        Sherlock

        I understand what you are saying, however the evidence free assumption in this article is that “unsupervised” CRNAs are somehow less safe. You can be sure that if this was the case, after over 100 years, CRNAs would not be able to work independently in every state in the union (which we do). 

        I read the article by Mark Warner, it isnt at all compelling as you well know. The proof, as it were, is in the pudding. As any risk management professional will tell you, one major lawsuit would wipe out any savings and therefore not be worth the risk. As I am sure you are aware, there have always been independent practice CRNAs in every state of the union and this contingent only continues to grow. Clearly, as demonstrated in the MJ case also mentioned here, the additional training a physician gets guarantees nothing.

  • http://twitter.com/redbirds12 John Key

    I have worked with many fine CRNAs but as a general surgeon the problem I always had was:  when things are going well in the operating room, CRNAs act like they’re a doctor; when things go to hell, it’s suddenly, “Hey doc, what do I do, I’m just a nurse”.  Since at that point the surgeon is up to his neck in alligators too, it’s a heckuva time for them to lose their confidence.

    • Anonymous

      Does this mean that we should lose confidence in a surgeon who has to consult a colleague while doing a surgical procedure or when he or she has a question about the management of condition? I’ve seen some very skilled surgeons request help in the OR and it never made me think less of them as physicians .. maybe all along it should have???

    • http://pulse.yahoo.com/_XK2MFFDKGVWZAIWA4WLQHC5GEA Sean

      Properly trained CRNA who has opted for independant setting should know their capability before going into such a role.  Furthermore, should know who they have for back up… if  anyone.  Lastly, a properly trained CRNA will know they are at the “head of the table” and will either manage it, or tell you to close now and wake the pt.  Given that… if it can’t be stopped… “oh well doc…better start compressions and code the pt. because intraoperative arrests happen…. and they don’t check first to see if anesthesia is a CRNA or MDA… because it happens to them both… even independant in the room entire case MDA who never left the room and patients die under sole MDA care too.

  • Anonymous

    I am a military CRNA and have just spent the last year working independently in Afghanistan on a Forward Surgical Team with no Anesthesiologist.  I provided safe anesthesia for some of the worst traumas imaginable to American soldiers, civilian adults and children.  I would have loved to have an extra hand in the OR from an Anesthesiologist but not to many are volunteering to go to Afghanistan and supervise CRNA’s there.  

    • Anonymous

      Thank you …

    • Anonymous

      Dear Military CRNA– I think I speak for us all in saying that we have nothing but the deepest gratitude for all military personnel who serve in forward units under the most adverse conditions.  My post refers to mainland settings where anesthesiologists are immediately available, either in military or civilian hospitals.  The anesthesia care team model is safe and cost effective, and has been so for many years.

      Karen Sibert MD

      • http://pulse.yahoo.com/_XK2MFFDKGVWZAIWA4WLQHC5GEA Sean

        One example then…  Why are independant CRNA’s providing much, if not most anesthesia in Endoscopy centers, eye clinics, Plastics centers, and free standing surgery centers in most of America today??  Is it only because there are not enough anesthesiologists in the USA to truely supervise 4 to 1??  Furthermore, what about the places like Provo Utah or BFE where it seems ologists don’t want to live??  Seems to me MDA’s are “selective” in where they want to supervise or where they feel anesthesia should be given.  In honest of full disclosure… I do work in an ACT model…. but do my own spinals unsupervised, and frequently “go to sleep” on my own… not just ASA 1 or 2 either…. 3 and 4 as well.  No CRNA in such a model would ever put a patient at risk out of ego either… I myself have pressed the proverbial “hold” button on patients for GETA inductions for either airway, unstable pre-op VS after Midazolam etc… even after being told by BC’d MDA to “go ahead”, in airway example was a potentially difficult airway on exam that was proven after induction with myself and MDA at bedside…. CRNA DLx2 unsuccessful, MDA DLx 2 … Unsuccessful….Glidescope by MDA x1 unsuccessful, then Glidescope attempt  2 by CRNA (with inflation of ETT cuff with end of ETT at glotic opening)… YEP, Successful!!    So, if we want to say education, training, technique, etc…. Does this make the CRNA with less than 3 years practice the better airway manager versus the 8+ B.C.’d MDA??    Point is, for safety… best model can often be 2 anesthesia providers there on induction, emergence etc…. does not necessarily have to be an MDA, depends highly on the providers skill, and overall knowledge…  I myself have seen surgeions bitch out an MDA who they felt did not know what the hell they were doing and impeding the surgeon’s goals.   There are good providers of anesthesia and bad…. CRNA and MDA alike.

      • http://www.facebook.com/armygas Michael Bentley

        I find an anonymous source not very credible. (referencing the “navy anesthesiologist”)

      • http://twitter.com/mmacfn1 Mike MacKinnon

        Karen

        Your op ed lacks any evidence whatsoever. That is the problem. It is ‘evidence by proclamation’ and using fear mongering. Look, if you (ASA) would just admit for once this is just about business and protecting your wallets I could at least understand it. However the continuous insinuation that this is a “safety” issue for patients is neither accurate, evidenced or fair. 

    • Navy Anesthesiologist

      Thank you for your service.

      I’m a military anesthesiologist, on active duty.  I also moonlight as much as I can in an opt-out state, so I have a good bit of experience with military CRNAs, civilian CRNAs, and deployed circumstances.  There are some facts that you are either glossing over or just not aware of.

      First, military CRNAs are some of the best trained CRNAs in the United States.  I wish all CRNAs had the kind of training military CRNAs get.  Unfortunately, the schools that train your civilian colleagues are not producing comparable graduates.  There is a sizable population of CRNAs that are absolutely dangerous when unsupervised.  You should be proud of your training, but recognize it for what it is, and don’t for a minute believe that you and your military colleagues are typical of what’s out there.

      Second, in CONUS, military CRNAs are generally NOT unsupervised.  At the Navy big three hospitals, they are required to consult their assigned anesthesiologist for ASA 3 and 4 patients.  Moreover, scheduling is done by an anesthesiologist, and CRNAs are given cases that are HEAVILY slanted toward the young and healthy outpatients having relatively minor procedures.  You don’t see “independent” CRNAs doing hearts or heads or sick ICU patients.  Outside the Navy big 3 hospitals, at the smaller Navy hospitals, the acuity is incredibly low.  It is a falsehood to pretend that military CRNAs are independently treating all comers.  (I can’t speak to what the Army and Air Force do but I suspect it’s no different.)

      Third, while deployed, military CRNAs indeed do practice independently … in some places.  However, they’re treating the healthiest and most aggressively and completely pre-screened patients on earth: young active duty military.  Further, they’re only doing trauma.  Formulaic and procedural … and let’s be honest, even the local national casualties generally aren’t sick.  They’re generally not vasculopaths, they don’t have end stage renal disease, or cirrhosis … and let’s be even more brutally honest, even if the local national patients are sick and they do die, there’s no family waiting to sue in the wings.  And then there’s the Feres Doctrine protection.  It is disingenuous to pretend that adequate care from independent CRNAs in Afghanistan proves or even implies that CRNAs should be working independently in the United States.

      Fourth, it is telling that within Afghanistan, there are fewer and fewer independent CRNA billets, because more and more deployed units are insisting on anesthesiologists.  Keep an eye on the USMC locations.

      Fifth, your parting shot to military anesthesiologists (“not to [sic] many are volunteering to go to Afghanistan”) is simply wrong and insulting.  Taskings come down from higher echelons in the military, and we step up to fill them just as you and the CRNA community do.  Right now, I’m on the books to go.  It will be my third deployment.

      • Curt Bergstrom

        Navy Anesthesiologist makes several excellent points that I would like to echo:

        1. The navy trains all its own CRNAs and doesn’t recruit CRNAs trained elsewhere. That ensures consistently high level of training that could not be achieved otherwise. To apply conclusions drawn from the practice of a limited sample of CRNAs with all the same training to the general population of CRNAs is a set up for trouble.
        2. Any illusion of independent practice disappears when trouble develops. Whether it is due to the patient’s comorbidities or the mismanagement by the CRNA, no anesthesiologist is going to tell them that they’re independent practitioners and they can fix their own problems. We will never have statistics on these saves because to collect such data might skew CRNA behavior toward calling for help even later than they already do.
        3. The decision to fill deployment positions with anesthesiologists vs CRNAs is made above the level of specialty leaders who are not in a position to say that no one on their bench wants to play.

        • http://twitter.com/mmacfn1 Mike MacKinnon

          Prove ANY of this.

          Talk about propaganda….

  • http://www.facebook.com/armygas Michael Bentley

    In fact, a highly respected anesthesiologist, R.K. Stoelting, MD wrote the following in the December 1996 issue of the journal Anesthesia and Analgesia:

    “… Unchallenged acceptance of the conclusion that evidence supports a specific method of anesthesia care delivery to be the “safest and most cost-effective” is misleading to patients, colleagues and those responsible for shaping health care delivery policy… 

    …. Likewise, the participation of certified registered nurse anesthetists (CRNAs) in delivery of anesthesia care would have ceased many years ago if there was evidence that this participation resulted in a less favorable outcome compared with anesthesia personally administered by an anesthesiologist…..” 

    ….Judging quality of anesthesia care on the basis of outcome(mortality) is unlikely to show a difference between personal delivery of anesthesia by an anesthesiologist and anesthesia care that includes a CRNA, with or without medical direction…” 

    Again, from the December 1996 issue of Anesthesia and Analgesia, , J.P. Abenstine, MD and Mark A. Warner, MD state: 

    “…The argument that superior education and experience will always offer better outcomes is inconsistent with any available data, whether in reference to anesthesia care, obstetrical care, or many other medical and nonmedical activities within society. You may need to be an electrical engineer to design a television, but you don’t need to be one to fix one….”

  • http://pulse.yahoo.com/_T4D4DSUXB4YECMFJTQ7MM227ZQ Sherlock

    Michael - 

    • http://pulse.yahoo.com/_XK2MFFDKGVWZAIWA4WLQHC5GEA Sean

      Good point… If MDA delivered care is definately the most “safe”, then let them sit on a stool one case at a time and eat what they kill ($$$$) only …..  No benefit then from taking 50% of the CRNA generated $$’s  Dont really see that happening…. 4:1 ACT model gives you 200% in the buckaroo dept.

  • Anonymous

    In this day and age, anesthesia has become extremely safe. The available monitoring equipment, medications, and knowledge gained through research and development has advanced this profession to the point where severe complications are a rarity. With that being said, complications still do occur. And when they occur, they are often unexpected and require a quick response. Closed claims reviews have shown without a doubt that having an anesthesiologist and a second provider in the operating room on induction and emergence provides the safest delivery of an anesthetic in the event of a catastrophic complication.

    In this issue of Anesthesiology, Arbous et al.1 provide a jolting report on the positive impact that anesthesia providers can have on their patients. How? Simple anesthetic management principles seem to have a major effect on perioperative mortality. The routine use of an equipment checklist (odds ratio, 0.61), direct availability of an anesthesiologist to help lend a hand or troubleshoot when needed (odds ratio, 0.46), the use of full-time compared with part-time anesthesia team members (odds ratio, 0.41), the presence of two members of the anesthesia team at emergence (odds ratio, 0.69), and reversal of muscle relaxants at the end of anesthesia (odds ratio, 0.10) had dramatic, positive effects that were associated with reduced perioperative mortality within 48 h after surgery and anesthesia.
    This report is remarkable in several ways. First, it is one of the few that have shown anesthetic management processes to dramatically reduce perioperative mortality. Second, it reports perioperative mortality rates matching a number of recent reports. Importantly, it supports the recent insightful article by Lagasse2 about perioperative mortality and his suggestion that the US anesthesia community may have overestimated its impact on improving patient safety in the past two decades. Finally, the authors have used a unique and thoughtfully planned multiinstitutional survey and case-control methodology to evaluate this low (but not low enough)-frequency outcome.
    It should not be surprising that perioperative anesthetic management processes can make a difference. The US Federal Aviation Administration has long required the use of pilot checklists for evaluating the airworthiness of aircraft and starting procedures, a requirement strongly supported by outcomes of real and simulated air flight. Why would our specialty, so often compared to piloting, be different? The Federal Aviation Administration also requires two pilots for most commercial aircraft operations, nicely matching the report’s finding that the presence of two anesthesia providers at emergence is associated with lower perioperative mortality. The positive impacts of immediate availability of an anesthesiologist when needed and continuity of anesthesia providers in the care of individual patients likewise make sense but, until this study, rarely have been shown to be associated with reduced perioperative mortality.
    Have we really overestimated our positive impact on patient safety? Clearly, a number of recent studies suggest that our oft-quoted estimate of 1:200,000 or more patients who have an anesthetic-related death may be flawed.2 The basis for this estimate is accurate but usually misinterpreted. Eichhorn et al.3 reported this low rate of anesthetic-related mortality in healthy patients, an important distinction occasionally neglected in anesthesia patient safety statements. This current study, like others, suggests that the anesthetic-related mortality rate is still too high. The good news is that we have room for improvement and, now, data to support anesthetic management changes that may help.
    The study of rare medical events is extremely difficult; it often is extraordinarily frustrating to obtain numerators large enough or denominators that are sufficiently robust to allow calculation of frequencies of the events and subsequent analyses for potential risk factors. Arbous et al.1 have used a multiinstitutional study technique common to clinical research in other medical specialties, notably cardiology, but infrequently attempted in anesthesiology and the study of perioperative mortality. This process has provided the authors with (unfortunately) a sufficient number of perioperative deaths to allow case-control analyses, a good way to seek associations between rare events and potential risk factors.
    In general, efforts to seek associations between rare medical events and potential risk factors follow a progression. First, case reports and small case series describe unusual outcomes. If enough of these unusual outcomes can be gathered (typically at least 20 are needed, assuming valid controls can be assessed), a case-control methodology can be used to seek possible but not proven risk factors. Subsequently, potential risk factors identified by case-control studies must be evaluated prospectively in large populations to ascertain their validity. Finally, potential interventions to decrease the frequency of these rare events can be tested in randomized, prospective trials. The current study’s elegant methodology takes advantage of the large numbers of perioperative death reports that they collected in multiple institutions by creatively and prospectively seeking data from randomly selected controls within each of those institutions. This methodology is applicable to many rare perioperative events and should be a model often copied in the future.
    Although conclusions from one study should not lead to wholesale changes in practice, the findings in this study support many plausible assumptions that improvements in anesthetic management processes can positively influence patient outcomes. The use of equipment checklists, immediate availability of anesthesiologists to help when needed, especially to provide extra assistance at emergence from anesthesia, and routine reversal of muscle relaxants are processes that should be seriously considered when seeking opportunities to improve the perioperative outcomes of anesthetized patients.
    Mark A. Warner, M.D.
    Mayo Clinic College of Medicine, Roches-ter, Minnesota. warner.mark@mayo.edu

  • http://www.facebook.com/people/Terence-Ivfmd-Lee/1523282856 Terence Ivfmd Lee

    Does title and degree trump experience and skill? Imagine that you are 35, have mild diabetes (ASA II) and are about to undergo bowel resection. Your surgeon has privileges at two facilities and gives you your choice. He tells you that one is staffed by CRNA’s, who have each done about 2000 of these cases (supervised) over the past decade. The other is staffed by board-certified MD’s. Your insurance has different contracts with these facilities and it will cost you an additional $500 out of pocket if you go to the MD one. Which would you choose?

    • http://twitter.com/#!/CloseCall_MD Close Call

      I believe the author’s talking about unsupervised CRNAs.  So a more apt hypothetical would be: would you rather have your surgery done by an unsupervised CRNA fresh out of CRNA school or an anesthesiologist fresh out of residency.  (let’s put them right at the level of training when they’d be out on their own).  The anesthesiologist is $500 more. 

      Anyone know how many clinical hours are put into a CRNA program vs med school and anesthesiology residency?  And no fair counting the first two years of med school or any classes the CRNA might have.. I’m talking direct patient care and contact… experience?

      • http://www.facebook.com/people/Terence-Ivfmd-Lee/1523282856 Terence Ivfmd Lee

        Fair enough. In an actual scenario where my only choices are a INEXPERIENCED CRNA or an INEXPERIENCED resident straight out of training, I’d spend whatever time/energy it takes to have my case done by neither. But if supervision is the factor in question, I’d still choose an experienced UNSUPERVISED CRNA over an experienced MD. I don’t see anything wrong with somebody else choosing the MD at a higher cost for themselves, because I believe people should have the freedom to choose what they do with their own resources.

        • http://twitter.com/pinkyvenky pinkyvenky

          Who said your anesthesia offered by a CRNA is cheaper? Have you not read the whole article?

          • http://www.facebook.com/people/Terence-Ivfmd-Lee/1523282856 Terence Ivfmd Lee

            Nobody said that it is universally cheaper, nor universally more expensive. Each situation is different, so I would evaluate the cost, quality and other factors that affect my personal preference and make my decision freely. I would also respect the rights of other people to make their own decisions after doing their due diligence to gather intel. If they want a CRNA, fine for them. If they want an MD, fine for them.

          • Anonymous

            “If they want a CRNA, fine for them. If they want an MD, fine for them.”

            As a two-time surgical cancer patient, I was never offered the opportunity to chose my anesthesia provider. I didn’t know I could. In fact, I only met them for the first time while being prepped in pre-op. After reading this discussion they will now be included in my research along with the surgeon and hospital.

             

          • http://www.facebook.com/people/Terence-Ivfmd-Lee/1523282856 Terence Ivfmd Lee

            I think choice in our medical care is highly desirable. What can we do to increase each patient’s access to information and consumer freedom?

  • http://www.facebook.com/profile.php?id=862515231 Warren Amyx

    Evidence Please. There is none to support this biased and politically motivated diatribe. CRNAs have been involved in anesthesia care for a long time , and have continued to provide safe care to millions of patients. This article does nothing to promote patient safety .. It is politically motivated to secure a position of superiority that has not been proven by any other means than anecdotal reports from people such as the author of this .
        Also to demean the CRNA’s that daily provide care to many of our service men and women both here and abroad is really unwarranted. I mean please lets stick to facts.

  • http://www.facebook.com/armygas Michael Bentley

    Did you know that because of the safety of anesthesia that if a study were to be partaken that the sample size would have to be well over 3,000,000 patients to have sufficient power to detect if in fact there was a difference?  Please, provide statistical evidence to support your anecdotal claims.  Anecdote does not equal data.  

    • Navy Anesthesiologist

      It would be unethical to do such a study properly.

      What are you going to do – randomly assign patients to unsupervised CRNA vs anesthesiologist care?

      a) First of all, you’d never get informed consent for that; no layperson is going to choose nurse care over doctor care if they are clearly given all of the information and a choice.

      b) It would be reckless and dangerous to randomize all patients, with all comorbidities, for all surgeries to either nurse or physician anesthesia.

      I work in a very rural area of an opt-out state.  The overwhelming majority of them aren’t doing the same cases anesthesiologists are.  I see this EVERY DAY.  The CRNAs are assigned to the urology cases and do cystoscopies all day, or they do healthy orthopedics, or they do hernia repairs.  The patients getting colectimes, or anything in the chest, or neurosurgery are assigned to anesthesiologists.  100% of patients are pre-screened at a preop visit by – you guessed it, an ANESTHESIOLOGIST.

      They freak out if a 90-year-old hip fracture with a history of “heart murmur” comes in at night.  They don’t know how to evaluate those patients and decide if they really need to wait until morning, or if cardiology really needs to see them.

      And I won’t go into further detail on a public forum, but suffice it to say it’s is crystal clear where the huge majority of our (low) morbidity and mortality comes from.  Despite the heavy slanting of sick/difficult cases to the physician anesthesiologists, the complications and problems come from the CRNA side.  I’m not just talking about sentinel events – I’m also talking about things like postop pain, nausea, multiple-hour stays in the PACU, unplanned admissions.

      Yet your/their claim of “completely independent and equal” practice persists.

      Everywhere I’ve been, only the ex-military CRNAs know how to do any regional anesthesia.  The civilian CRNAs here can’t do blocks.  They can’t place lines.  They can’t do MANY things that are critically important in sick patients.  Even if a patient might be better served by regional anesthesia, they’ll pick general anesthesia because they can’t do basic blocks.

      If I had a nickel for every time I, as the 2nd call MD behind a 1st call “independent” CRNA, have been called in to do a case they can’t do, or don’t feel comfortable doing, or the surgeon WON’T LET THEM DO, I’d have enough change to clean out a vending machine.

      It’s frustrating to debate these issues with you, because your side always reverts to “there’s no evidence” when the basic problem is the studies that would have to be done are impossible because randomizing patients to truly independent nurse care is unsafe and unethical.

      You may as well lament the lack of data supporting the safety of “parachute” vs “no parachute” for people jumping out of airplanes.

      We hired a civilian CRNA contract to help out for a while at the military hospital.  He had ZERO regional training prior to coming here.  He hadn’t even done more than a handful of epidurals for healthy laboring women.  Smart guy, hard worker.  But his training was simply incomplete.  Your association has done a terrible job of enforcing minimum standards for graduates.

      Your photo shows you wearing a uniform, so I assume you’re in the Army.  As an Army CRNA, you’ve had top tier CRNA training.  You should NOT assume that all of your civilian colleagues benefited from the same.  The AANA has done a terrible job of enforcing minimum standards for CRNA mills.

      Even the best CRNAs deserve backup, support, and direction from an anesthesiologist.  Some need it more than others.  It is inappropriate and reckless to pretend that a majority of CRNAs in this country are capable of genuine independent practice.

      • stanley kristiansen

        I myself perform all of the regional you describe do the colectimies et al without supervision.  I did not go to a military program just an average program.  If I were to extraploate the whole of a profession in the manner you do I would say that for the most part anesthesiologists are exceddingly incapable providers unable to make competent clinical judgments are unable to perform regional anesthesia.  I could base this on the actions I have observed in several locums positions in the past.  Wow what a thoughtful relevent observation just like yours.

        If you really want to see a problem it is in the unlimited authority to practice medicine granted by an MD license, you cannot pick up a journal or paper without reading about some MD who performed procedures they were not adequetly trained to perform and killing a patient, propofol Mr. Jackson?  sure no problem I am a DOCTOR.  The sooner that strict scope of practice is placed upon this group of cavilier clinicans who do not know what they do not know and are willing to let patients suffer and die because of ignorence and ego the safer the patients will be.

        • Anonymous

          Interesting example you cite. Dr. Murray was clearly working outside his own scope of training and practice in choosing to treat MJ with propofol in an unmonitored setting. He didn’t know what he didn’t know, yet he went ahead anyway. Who does that sound like? I’m an anesthesiologist specializing in pain medicine. I don’t attempt spine surgery on my patients because I don’t have the training. If I did, I would be just as guilty as Dr. Murray and every single nurse pretending to be something she is not. 

          • http://twitter.com/mmacfn1 Mike MacKinnon

            Stigg

            the great point here is that “all that extra” medical training and “knowledge” I constantly hear being bantered about by the ASA meant NOTHING. That is what it means. The rests of the anesthesia training that MDAs and CRNAs all get isnt vastly different.

  • http://www.facebook.com/armygas Michael Bentley

    Sherlock if something “cannot be measure by outcome statistics” then it is pure speculation without proof.

    • Navy Anesthesiologist

      Despite the difficulties of really studying the issue, there is growing evidence that the anesthesia care team (ACT) model, in which CRNAs work with and are supervised by an anesthesiologist, reduces perioperative morbidity and mortality.

      Here’s just one

      http://www.ncbi.nlm.nih.gov/pubmed/15681938

      The ACT model is cost effective and safe.  It is endorsed by the American Society of Anesthesiologists.

      I’m not arguing against CRNA independence because i have an economic interest in doing so.  Remember, I’m in the military and earn a government salary, which is actually about 20-40% less than what the full-time “independent” CRNAs across town are earning.

      The AANA’s push for independence is PURELY for the economic benefit of its members.

  • http://www.facebook.com/profile.php?id=616080309 Murray Yazer

    As an outsider to American medicine, this is a very interesting discussion.  I am a 4th year resident in anesthesiology in Canada and I work in a system without CRNA’s so I have no firsthand working with them.  I am curious about what exactly the scope of practice of a CRNA is.  Do you perform neuraxial techniques?  Thoracic epidurals?  Brachail plexus blocks?  Do you place central lines and arterial lines?  Do you manage obstetrics and neonatal resuscitation?

    Thanks,
    Murray

    • http://www.facebook.com/armygas Michael Bentley

      Yes to all the above.

  • http://pulse.yahoo.com/_XK2MFFDKGVWZAIWA4WLQHC5GEA Sean

    Seriously??  Uh huh… As if an all independant 100% CRNA practice is going to hire a new grad?  Even if they did, it would not be many.  And who do you think in such a practice setting is doing the pre-ops and formulating possible plans for a case…. the new grad CRNA, or the CRNA in the practice with 20 years experience, and over 25,000 anesthetics??  Fortunate thing about all CRNA practice is that the whole team works together….sure a newer CRNA may do the spinal etc for a joint replacement… but to seriously think they are just going to come in an pop in a femoral nerve cath or central line without supervision or instruction or clinical privilaging competency evaluation is simply ridiculous and frankly simply giving potential patients the wrong information.  I personally know CRNA practices do what is right for the patient…. one CRNA simply does not “do it all” until they have “done it all” – i.e. Military CRNA’s …. who can typically run circles around many anesthesiologists I have seen.

  • Anonymous

    Yes, CRNAs are trained to do neuraxial techniques, all blocks, art lines and central lines. I think the amount of “training” here is the big issue. It isn’t fair to compare a new grad CRNA to an anesthesiologist right out of residency simply because the MDA does have more training under their belt with a residency of 4 + years. A new grad
    CRNA has maybe 2 years at most of
    clinical training after or incorporated into their didactic coursework. A fair
    comparison would be a CRNA two or three years post graduate and a new
    anesthesiologist.

    Regardless of who provides your
    anesthesia, the initials behind the name
    are meaningless when it comes to
    safety. Having MD or DO as your title
    does not automatically make you a good anesthesia provider. The key is being vigilant and doing what is best for the patient. In my experience, CRNAs are perfectly capable of providing a safe anesthetic to any patient. It is definitely best to function in a group where there is help when needed. But that help can come just as easily from a more experienced CRNA as it can from an anesthesiologist.

  • http://www.facebook.com/armygas Michael Bentley

    A reply to that very article:

    “Anesthesia Risk Factors Not Proven by Case–Control Study
    Schmidt, Kenneth A. M.D.
    Author Information
    Valley Hospital, Ridgewood, New Jersey. kschmidt99@aol.com
    (Accepted for publication June 20, 2005.)
     To the Editor:— I applaud Arbous et al.1 for attempting a large multicenter study to identify anesthesia care factors that may cause mortality. However, the design of the study could allow for misleading conclusions. Failure to have controls of similar case type resulted in the conclusions that two anesthesia personnel at emergence, reversal of neuromuscular agents, postoperative pain medication, and no anesthesiologist relief were associated with less mortality. My previous experience at a trauma center is that patients who die often have long surgery at night when anesthesiologists change shift. After surgery, the patient is kept intubated and transported to the recovery room without need of additional anesthesia personnel. The neuromuscular agents are not reversed, and the patient is often too unstable to receive opiate pain therapy. Proper selection of control cases would show that this method of anesthesia care did not cause the death of the patient. There is an old joke that oxygen is the most dangerous anesthetic, because all trauma patients who receive only oxygen for major surgery die. It is no joke when the lack of proper controls in a study leads to conclusions that will be quoted to change proper anesthesia care. The editorial by Dr. Warner 2 was correct to state that case–control methodology does not prove that these are risk factors. This should have been stressed by Arbous et al. Kenneth A. Schmidt, M.D. Valley Hospital, Ridgewood, New Jersey. kschmidt99@aol.com

  • http://www.facebook.com/armygas Michael Bentley

    Also the study was setup based upon “assumptions”….. absolutely no controls.  In fact here is the author’s own quote:  ”
    Assuming that the prevalence of anesthesia management risk factors is 5% and that the incidence of perioperative death is 1:10,000.”  Interesting that there quoted mortality is 20-40 times greater than the numbers published by the ASA, the Journal of Anesthesiology, etc.  In the words of the NFL Gameday crew… “Come on man!”

  • http://www.facebook.com/armygas Michael Bentley

    Regardless of the anesthesia provider, anesthesia is safe.  In fact here is a bit of information taken from a Harvard lecture on Anesthesia Safety:

    Anesthesia mortality has fallenfrom 1/ 3,000 in 1985to 1/ 30,000 or 1/300,000in 1996 (and has remained there)1/295,118 = 6 sigma

    Please note that this is 15 years ago.  It is commonly accepted by many authorities to be over 1 in 400,000 today.  Anesthesia is six sigma regardless of the provider.  

    Also,

    I would like to bring to your attention comments made by the Mark Lema, MD, PhD who was President of the ASA in 2007.  He gave a lecture at the ASA Practice Management Conference titled “21st Century Anesthesiology – Preparing for the Future Paradigm”.  He first begins by detailing the shortage of providers by stating that the expansion of anesthesia services into offsite/unusual anesthetizing locations creates greater demand with reduced efficiency.  He then admits that the Pain Medicine specialty has further depleted MD Anesthetists.  In the next slide he expresses the financial motive for the argument portrayed in the editorial written by Dr. Seibert.  At this conference he admits Value=quality/cost + access.  He states “Society will solve the anesthesia provider shortage/high cost of care by allowing others to partake in anesthesia care to drive down prices and improve access.”  So as you can clearly see this is a financial turf war because safety has not been mentioned by Dr. Lema at this conference to this point.  He then shows a slide where anesthesiologists are the 4th highest paid specialty behind radiology, orthopedics, and gastroenterology.  Still no mention of safety to this point, only money.  The next slide is titled “Telltale signs that we may be on a salary bubble”…… still about money, not safety.  The “money” section ends with a slide titled “poachers and dabblers” in other words, “threats” to anesthesiology compensation.  Now I can provide this slide set to anyone please email me at armygas@gmail.com and I will gladly send it to you.  Dr. Lema then reviews U.S. efficiency in the world in delivering healthcare in which we rank last compared to the other industrialized nations.  Finally he gets to the “Future of Anesthesia Practice”.  In this section he reviews the findings of MF Weiss given in The Resource #61 7-8/06.  In this section there is a slide that gives these two quotes, “… payor battleground battleground…they are price sensitive, not quality sensitive… genetically predisposed to go with the CRNA [cheaper] cheaper]”….. “CRNA practice is here to stay. And the trend is toward independent practice practice…”This is very interesting.  The word “quality” is used but not “safety”.  Why?  Because safety is not the issue.  Nurse Anesthetists have delivered care for what now 150 years?  The issue of safety is the same argument used in 1921 (I can send you that article as well…. interesting that the debate today is the same as it was in 1921. Dr. Lema concludes his speech by telling the forum how to plan for future changes in Anesthesiology.  Please note these statements in particular:  1.”We must be both medically and financially prepared to expand our ACT supervision to an ICU-type medical direction (10:1) using CSNs along with CRNAs” and 2. “Independent Practice for CRNAs is a very likely prospect to be promoted by AHA and Hospital CEOs to lower costs and ‘expand’the workforce as access to care diminishes. We must factor this possibility into our plans to be both competitive and cost-effective.”Where is the mention of safety?  There isn’t because it isn’t the issue, money is…..Safety FINALLY comes up in the talk and he presents a slide which shows Anesthesia safety as 1:300,000 and “best in class”.  There is no differentiation of provider type.  There is a very large admission by Dr. Lema that Safety research is lacking and difficult.  He states that the plural of ANECDOTE is not DATA and that GOOD studies are needed.  (but that will be hard to do if you need a sample size of 3,000,000 based upon the effect size).  He makes this statement: “Research in outcomes and safetyare needed to show our value to patients, colleagues and payers comparing us with both non-MD providers (CRNAs) and non-anesthesiology MDs (ICU/ER).”  It is of note that he felt the need to bold the words “outcomes and safety” and “value”.  I would speculate that value was the key at that meeting. Again this is a turf war about money… that is it.Lema then quotes Dr. Reves: “Our lackluster research effort must improve for a field with as many bright people as we have in it.It must improve for a specialty as old and mature as we now are. It must improve if we wish to advance anesthesiology. It must improve if we wish to sit at the table as peers with our academic colleagues in the halls of academe.……for if not, I fear a future where anesthesiology , will be viewed merely as a necessary, but only a technical specialty, irrelevant to mainstream medicine.medicine.”So again, this is about money not safety.

  • http://twitter.com/#!/CloseCall_MD Close Call

    Agreed that the level of training is key.  But when a professional service is deregulated (or the regulations are loosened), it creates ambiguity in the skill set of the provider.  A new, unsupervised MDA will have thousands of more hours of clinical experience than a new unsupervised CRNA.  Will patients understand this difference?  Will they think to ask about it?  Educated patients will, the majority will not.  

    If, as some people have commented, that new CRNA’s would RARELY be hired right out of school due to their inexperience, and that an MDA can only be fairly compared to a CRNA with 3 years of post grad work, then why legally allow independent CRNAs right out of school?  Doesn’t it make sense for them to go through some mandatory post-grad or supervised training process first before they’re allowed unsupervised, say for 3-5 years – like a residency?  I think I’m missing something…. but then.. that seems to happen a lot.

    • Anonymous

      One great big fact that is never brought up in these discussions is the fundamental difference in brainpower of the average CRNA vs the average anesthesiologist. Sure, there are plenty of smart CRNAs who I respect as colleagues and would love to have by my side in a pinch. But there are plenty more who are “just nurses”. The ones who are fine with that and happy with their scope don’t worry me. It’s the wannabe “doctor” nurses that give me the willies and compromise patient safety. Look at the typical credentials of an MD versus a typical CRNA. The MD graduated from a top 50 (more likely top 25) undergraduate college, often in a difficult major, and earned a 3.5 or higher. MCATs > 30 are nothing to sneer at and medical school admission is nothing to blow off. It takes some ass-kicking brainpower to achieve these credentials. MDs tend to forget about these stats because we’re surrounded by people with similar achievements- but that’s exactly my point. The MD brain pool is far deeper than what you find in the nursing community. Barring the socially awkward or bottom of the class MDs that somehow slip through, when you get MD level care, your getting a broadly educated individual who has been overcoming big challenges successfully their entire life. And some militant CRNAs want to convince people it makes no difference whether an MD is involved and immediately available or not when things start going to hell in the OR. This doesn’t even pass the straight face test. Medicine in the US is in the process of being dumbed down in a misguided attempt to save money by performing a bait and switch of gigantic proportions. Medicine’s OWS moment is coming. It’s just a matter of time until the high profile lawsuits come and the tide reverses. 

      • http://twitter.com/mmacfn1 Mike MacKinnon

        Stigg

        Dude you are clueless and insulting. If this “event” has not happened after billions of anesthetics and 120 years of CRNA independent practice it isnt happening.

        As your own Mark Warner said in 1996..

        December 1996 issue of Anesthesia and Analgesia, , J.P. Abenstine, MD and Mark A. Warner, MD state: 

        “…The argument that superior education and experience will always offer better outcomes is inconsistent with any available data, whether in reference to anesthesia care, obstetrical care, or many other medical and nonmedical activities within society. You may need to be an electrical engineer to design a television, but you don’t need to be one to fix one….” 

        • Anonymous

          Anyone who would reject better stock, training, and experience in favor of the opposite where their own life, or the life of their loved one is concerned is insane or LYING. Mark Warner’s opinion is just that. I know the anesthesiologist who did Bill Clinton’s heart surgery. CRNAs were no where near that room. VIPs and the rich can always demand the best care, but it’s bait and switch for the public. 

          I sincerely doubt we will ever see “data” to prove my point because of the nature of error correction in health systems. It’s like a stack of swiss cheese slices. There may be holes in each layer, but as long as they don’t all line up at once, badness is mitigated. No study is going to be thorough enough to go back and interview the participants in each and every operation to determine whether undocumented problems occurred where the CRNA needed a bailout from the surgeon or a nearby but non-supervising anesthesiologist. The best we have is  an assessment of stock, training, experience, and our common sense. CRNA independence is about money, the nurse ego, and their appalling lack of concern for public safety. 

          The ACT is a fine system to manage cost with risk and should be left alone. 

          • http://twitter.com/mmacfn1 Mike MacKinnon

            Ahhh

            I see, so more opinion and no evidence or facts. Shocker. If you think that people do not choose to have a CRNA over an MDA for their anesthesia you havent been in anesthesia long enough, it happens all the time by request, I know because Ive been requested. No one cares about your initials or where you trained they care about how well your patients do, that is where the rubber meets the road.

            Your argument about the rich demanding the best and assuming that means quality is absolutely strawman and you know it. While many will buy the most expensive of everything that does not translate into quality and that is a fact. You might not like Mark Warners statement but if you didnt know, it is born out in fact and he actually references it, it isnt an opinion it just does not agree with your opinion so you immediately dismiss it. There is no bait and switch, my patients do just as well as yours and no-one is telling me what to do or saving me. 

            You seem to keep forgetting that there is data. Hundreds of thousands of patients every year have anesthesia for cases with patients ASA 1-4 and every operation without the supervision of MDAs. They do just fine and come back for their next surgery without hesitation. The surgeons keep bringing their patients to us and the hospital risk management dept isnt trying to replace us because of risk. As you know, that risk is calculated by people whos job it is to determine if there is any. Guess what, there isnt anymore risk with a CRNA than with a supervised one or a solo MDA. That is a fact and the insurance rates, risk management and all available evidence agrees with me. Pretending it is a “public safety” issue is one of the most despicable and dishonorable arguments I have yet to see from your organization. If this was the case CRNAs working independently would have long since ceased to exist and you (and everyone else reading this) knows it. 

            Additionally, it isnt about money. I could go down the street to a GI center and make more than I do now doing crani’s and ex laps etc, work less hours and be off at 3 pm everyday no weekends holidays or call. So again, you speak without evidence or any basis in reality. 

            You mention ACT as a cost effective tool. Wow, you really do need a lesson in billing dont you. The only thing the ACT does is allow MDAs to make 200% of what they would sitting cases on their own. Essentially, paying 2 providers to do the job of one. Additionally, the MGMA survey shows that over 70% of ACT groups require the hospital to pay a stipend to the anesthesia dept making it a cost center, to maintain the high salaries of the MDAs who are generating little or no RVUs. This cost is directly passed down to the consumer as all costs are.  Not only is the ACT a burden upon the system financially but it is an absolute waste of resources and always has been. The one thing it does well is double an MDAs salary without requiring them to actually do anesthesia.

            You also mention risk in regards to the ACT. Even the poor research done by Silber (which every journal but Anesthesiology refused to print BTW), did not show that MDAs decreased any M&M. It simply showed that when there was another set of anesthesia trained hands there was benefit. However, it does not show those hands needs to be a physicians. Additionally, the risks were the same with MDA only vs CRNA only anesthesia. Again, disproving your opinion that there is risk with CRNA only care.

            Look, some of my best friends and mentors are MDAs. I have nothing negative to say about the care MDAs provide to patients. I have no problem competing in the market place and even joining a group where MDAs and CRNAs do their own cases. I see nothing wrong with CRNAs and MDAs who choose to work in an ACT. Where I have a problem is when there are attempts to defame my profession in a smear campaign with “evidence by proclamation” in an attempt to protect your collective wallets by fear mongering and propaganda. That is what this article is, evidence by proclamation and smear. Nothing more.

          • Anonymous

            Nurse MacKinnon, you may be the greatest CRNA to walk the earth, and if that’s the case I applaud your clinical skills. But the facts regarding the stock, training, and experience of your colleagues is completely relevant to this discussion. MDs enter the game at a much higher level than CRNAs do. They earn the right to their own independent practice through rigorous training that begins well before medical school. CRNAs take the crash course easy route into what should have been nursing, but with independence IS in fact the practice of medicine. Some will be up to the job. Many will not. But by legislating independent practice for CRNAs, you open up that possibility for ALL CRNAs regardless of ability. That is an incredibly reckless thing to do, and if you don’t see that, you really don’t know what you don’t know.

          • Anonymous

            “anesthesia for cases with patients ASA 1-4 and every operation without the supervision of MDAs. They do just fine and come back for their next surgery without hesitation.” 
            Mike please show me the data to back this up…all the data that I have read even the study published and payed for by anesthesia nurses points out the anesthesiologist do more complex cases than anesthesia nurses and with a trend to better outcomes when it comes to morbidity and mortality.  Every study shows a trend that anesthesiologist are a safer option.   Also I thought CRNAs billed medicare the same as an anesthesiologist so it doesnt make a CRNA cheaper since they get payed the same.  The fact that you keep ignoring is that newly graduated anesthesia nurse can’t perform independently like physician anesthesiologist are able to do.  Mike can you give the number of peripherial nerve blocks a anestheis nurse student has to “perform” prior to graduation…I believe the answer is they have to manage not perform 40…also how many central lines do they actually have to perform on a human, oh wait they do them on simulators and count them…what about the fact the they watch anesthesia physician residents perform anesthes on complex cases and count them as if they perfromed the anesthetic…honestly mike 95% of graduating anestheis nurses cant safely function independtly doing all cases  

        • http://www.facebook.com/profile.php?id=706294319 Cherie Binns

          As an RN for nearly 4 decades, I must say I would far prefer a nurse anesthetist to an anesthesiologist when needing anesthesia.   My experience (both form the professional environment and as a patient) is that the care rendered by the nurse anesthetist is far superior to that of the MD anestheologist in that more care is taken for patient comfort and education and patients seem to wake more easily with fewer complications from anesthesia.

          I don’t think this is a gender issue so much as an element of training that is severely lacking in a medical education versus a nursing education….patient comes first!  Nurses KNOW how to talk to patients.   Most doctors do not.   Add to that that the majority of the anesthesiologists with whom I have worked since 1970 use English as a second language and many of those do not have English mastered and that creates a communication barrier with the patients and OR staff and can lead to potentially serious , even fatal, medication errors.

          No, I do not even remotely agree with the point of view expressed by this physician/author.

          • http://twitter.com/pinkyvenky pinkyvenky

            It would be surprising if you agreed with the author. Wouldnt it be???

            You stated “care” provided by a nurse anesthetist is “far” superior to that of an MD anesthesiologist. How do you define this “care”. If your definition includes just providing “comfort” and “education”, then thats absolutely not enough.

            Just knowing how to talk to patients is NOT enough, though its very important. Lets say, you have a heart attack. How will a nurse talking to you make it better and save you from death?

          • Anonymous

            Nurse Binns, I don’t enjoy pointing out what I did in my original post. It’s unpleasant and certainly comes across as mean spirited. But when your CRNA colleagues make the argument that all my education, training, experience, and achievement is essentially irrelevant and unnecessary to the practice of my specialty, it’s hard to stay quiet and remain politically correct. A CRNA telling an MD what is and isn’t important about their specialty is childish and insulting, so please don’t be surprised when we react harshly. I’ve seen plenty of nurses viciously drop the hammer on a nursing student or MA when they overstep their bounds. 

            You bring up an issue that the nursing profession loves to use as a battering ram to assault the medical profession. That is the issue of bedside manner, communication skills, and how to talk to patients. Somehow nurses “care more”, and “treat the whole patient”. We have all met physicians who are uncaring arrogant jerks, and we can thank the baby boomer generation for much of this. I would encourage you to take a closer look at the younger generation of physicians trained in the last 10-15 years. This is the future of medicine, and I think you will be pleasantly surprised when you find medical schools have been emphasizing patient communication skills. My internship actually dedicated an entire month of training to this where we had no other clinical responsibilities other than to learn how to interview patients well, and discuss sensitive issues with care. 

            Last, don’t forget that bedside manner does not equal clinical skill. There are plenty of charlatans out there who hide clinical incompetence behind a cloak of congeniality. You might consider that the next time you consent to treatment “because he’s so nice”. 

          • http://twitter.com/#!/CloseCall_MD Close Call

            Me talk badly to patients?  That’s umpossible! 

          • http://twitter.com/KoKaiNoodles Mary Darroch

            Some very controversial statements there! Some may suspect a little  xenophobia lies a the heart of the post!

      • stanley kristiansen

        and they also dress better and gosh are ever so much cooler and heroic and handsome and….. and…. the inane nonrelevant superlatives have run out between you and I.  To bad an MD was not typing I am sure it would have been the equivilent to “war and peace”.

  • http://twitter.com/mmacfn1 Mike MacKinnon

    I call BS.

    Here are some quotes from your own association:

    R.K. Stoelting, MD wrote the following in the December 1996 issue of the journal Anesthesia and Analgesia:”… Unchallenged acceptance of the conclusion that evidence supports a specific method of anesthesia care delivery to be the “safest and most cost-effective” is misleading to patients, colleagues and those responsible for shaping health care delivery policy… …. Likewise, the participation of certified registered nurse anesthetists (CRNAs) in delivery of anesthesia care would have ceased many years ago if there was evidence that this participation resulted in a less favorable outcome compared with anesthesia personally administered by an anesthesiologist…..” ….Judging quality of anesthesia care on the basis of outcome(mortality) is unlikely to show a difference between personal delivery of anesthesia by an anesthesiologist and anesthesia care that includes a CRNA, with or without medical direction…” Again, from the December 1996 issue of Anesthesia and Analgesia, , J.P. Abenstine, MD and Mark A. Warner, MD state: ”…The argument that superior education and experience will always offer better outcomes is inconsistent with any available data, whether in reference to anesthesia care, obstetrical care, or many other medical and nonmedical activities within society. You may need to be an electrical engineer to design a television, but you don’t need to be one to fix one….”

  • WhiteCoat Rants

    I don’t see what everyone is so upset about. 
    In fact just this week, I was teaching my 11 year old how to provide anesthesia. I figure that next year, after he’s advanced to intubating raccoons and squirrels we find on the side of the highway and I certify that he’s competent in providing propofol drips, he’ll be able to work in an OR, and will be fully able to fund his college education.I know this will work because there are no studies showing how middle school children have any worse outcomes at providing anesthesia than department chairs at university hospitals. 

    At some point, society is going to reach a point of diminishing returns when sliding down the slippery slope of saving money by paying less to lesser-trained providers for performing patient care. If we accept that CRNAs are competent to provide care with their curriculum, how long will it be until we have “CRNA Assistants” who are allowed to provide the same care with “n-2″ years of training? I’m sure that there will be some small studies showing that there is no difference in outcomes. Bad outcomes don’t occur that often to begin with, so patients will be satisfied. Then CRNA Assistant Techs will be the next burgeoning professional classification with “n-4″ years of training.

    The white elephant in the room that everyone is ignoring is how well providers are able to deal with complications and unexpected events. If an ASA 4 patient’s tube becomes dislodged during surgery or if a patient goes into V tach and a student CRNA is in the room, staff doesn’t go running to look for a CRNA Assistant or a CRNA — they page an anesthesiologist overhead STAT. Would any of those arguing that CRNA training is “sufficient” dispute this point?  

    I personally don’t mind if CRNAs are allowed to practice independently. However, if a CRNA is going to provide care instead of an anesthesiologist, that fact, along with the amount of the CRNA’s training and experience, should be made explicitly clear to the patient BEFORE care is received. If a CRNA is going to be providing care, then it should be explicitly stated if there is a backup anesthesiologist and where that anesthesiologist will be. If I’m paying for the care, I’m going to be able to choose who I want providing that care. Personally, I want someone who knows how to deal with the unexpected emergency. 

    When things go wrong, nobody thanks you for saving them money.

    • stanley kristiansen

      A lesser prepared provider exists, funded by the ASA that bastion of saftey, it is called an AA.  Talk to the ASA about the middle school child thing I have no doubt if they can bill for it and control it then they will support your idea to the hilt.

  • Anonymous

    The continuation of the existing rule is good public policy.  Anesthesia has become a very safe part of the health care delivery system, and it makes common sense that the is due in part to appropriate supervision of non-physician providers. 

  • http://pulse.yahoo.com/_I5IV6ZMGNAIHXWB6QINY4NCNVI Joe Thorpe

    Always an interesting and passionately debated topic. My observation in healthcare education is that for mid-level providers across the board (PAs, CRNAs, etc) we dedicate a lot of time boosting their confidence to make them feel on par with providers who sacrifice far more time and resources to their education. This leads to a level of confidence that exceeds their level of practice.

    “you may not have nearly as much training, but you are just as good as…” with some caveats maybe. In this era of political correctness no one really wants to call things like they really are in regards to level of training and experience. Are MDs smarter than CRNAs? Some are, some aren’t. Are MDs better trained, definitely. CRNA acknowledgment of this is supported by the new push to make all newly trained CRNAs receive “doctorate” level education.

    If using independent practicing CRNAs is such a good model of safety and cost savings, why don’t our ever so cost conscious European counterparts embrace it? 

    • stanley kristiansen

      I realizre that by responding to you that I am boosting your ego, making you think that your point(?) has any validity.  As for the europeans they do use various physican extenders including nurse anesthetists, soo how about educating yourself?
      PS do not let your confidence get to high…..nitwit.

      • http://pulse.yahoo.com/_I5IV6ZMGNAIHXWB6QINY4NCNVI Joe Thorpe

        I appreciate the name calling very mature. 

        Trust me, there is no ego in it for me. That was the point of my post. The PAs I train with have their egos stroked all the time (“we have learn in 1 yr of clinical rotations what you have 2 years to learn” ditto CRNAs who have stated “I only have 18 months of OR time to learn what anesthesiologists learn in 4 years of residency”). 

        Honestly? How absurd. 

        So far throughout my medical education I have been pimped, humbled, scutted out, embarassed, etc all along the way. If there is any ego left, I am sure it will be destroyed by the end of residency. Then, after thousands of hours of training I will appreciate how much I do not know and hopefully not be tempted to practice beyond my scope of care. 

        I knew that the UK, Australia, Canada, and New Zealand did not have nurse anesthetists, thank you for educating me on mainland Europe. I will have to read into it.

        • stanley kristiansen

          No ego? Maybe not but no ability to recognize sarcasm either.  You did not appreciate the insinuation did you?  Well I did not appreciate the statment of my need for ego stroking, seeing as you do not know me at all.
          Maturity I think your generilized unfounded “ego stroking” comment destroyed any nacent maturity you may have/had?  Those who live in glass houses should not throw stones should they?

  • http://twitter.com/KoKaiNoodles Mary Darroch

    As a frequent user of the NHS in the UK, and having recently had surgery on a yearly basis, I would not trust anyone who cannot spell correctly to administer anaesthetics to me! 

    • stanley kristiansen

      I will do my best to insure that the champion of the spelling bee administers your anesthetics, regardless of the clinical capacity.  It is funny the things that the truly ignorant find important.

    • Anonymous

      Anaesthesia is the british form of spelling. In USA we spell it anesthesia so maybe you should research before you speak. Also, CRNAs now work in Denmark, Sweden, Switzerland, France (all countries with superb health care systems)and soon probably coming to you,…scaaaaryyy, huh?

  • http://twitter.com/KoKaiNoodles Mary Darroch

    As a frequent patient requiring anaesthetic on a yearly basis, I would not trust someone who cannot spell to administer correct dosage to me!  I am in the UK  and thank goodness we do not yet have this gloomy scenario. 

    • Anonymous

      Mary, I couldn’t agree more.  One wonders if the same laziness in spelling crosses over to sloppy prescribing of drugs.

  • Anonymous

    Before all you doctors rear up on your hind legs and start pounding your chests, I’d like to point out that anesthesia was a nursing specialty long before it was a medical specialty. Nurses have their own scope of practice and what advanced practice nurses (like CRNAs, CNMs, and NPs) are allowed to do is spelled out in most nurse practice acts. Instead of assuming that care provided by advanced practice nurses is “inferior” to care provided by physicians, why don’t you talk to advanced practice nurses and watch what they do and how they do it. You might be pleasantly surprised. And if I have a choice between an experienced CRNA and 2nd year anesthesia resident, who do you think I’m going to choose?

    • http://twitter.com/pinkyvenky pinkyvenky

      Why are you even comparing “an experienced CRNA” with a “2nd yr anesthesia resident” ???? I dont understand. Doesn’t make any sense.
      “If I have a choice”…..unfortunately most patients are not given a choice to choose an MD over a CRNA.
      As to your claim that anesthesia was a nursing specialty… as medical knowledge advanced a need for further training had been realized and more specialties have been born. 

      • Anonymous

        Anesthesia becoming a medical specialty had very little to do with science and everything to do with money, when someone figured out they could bill for anesthesia services separately. There are several paintings depicting 19th century surgery where it’s a nurse administering anesthesia.

        • Anonymous

          soooo, because something was done 100 years ago, it should be continued today as well

          • Anonymous

            You totally missed the point.

    • http://pulse.yahoo.com/_I5IV6ZMGNAIHXWB6QINY4NCNVI Joe Thorpe

      As a new third year medical student the “experienced” NP I was assigned to in clinic asked what we should do about an abnormal lab result. I thought she was trying to educate me at first, then I realized she actually wanted to know what to do with the result. 

      I have “watched” many advanced practice nurses over the last couple of years. My general observation is the ones who work within the construct of a care team of providers (including a physician in the practice) are much more likely to deliver current standard of care and be humble enough to seek an educated second opinion when needed. Most good physicians do the same by calling a colleague on the phone. Mid-levels who practice solo are another story. Years of solo practicing bad medicine do not equal an “experienced” provider. Certainly the same could be said about physicians, however the significantly greater number of hours of supervised training and rigorous licensing (and re-certification and CME) requirements mitigate much of this.If I understand correctly, CRNAs will join anesthesiologists and anesthesia assistants (who have had re-certification requirements for some time now)  in having some sort of re-certification exam starting in 2015. Which is excellent! This will coincide with many of the new ones receiving a “doctorate,” further acknowledgement of the need for additional training.   Obviously if given a choice between an “experienced CRNA” and a 2nd year anesthesia resident, I would have to answer, “depends on the CRNA” and depends on the “resident.”

      • http://twitter.com/mmacfn1 Mike MacKinnon

        Bud…

        You should have stopped right here “As a new third year medical student”. Sorry, you dont have a clue about anything yet least of all what anyone is capable of.

        • Anonymous

          A major problem with the way we educate health practitioners is that it’s done in academic isolation, even though there are some classes medical, nursing, pharm students, etc. can take together. There needs to be more interdisciplinary cooperation on campus BEFORE clinical rotations. The entrenched opposition of organized medicine against nurses, especially advanced practice nurses is one of the reasons why I’m going into forensic psychology.

      • Anonymous

         I think you’re observations are spot on, as the British say. It’s about teamwork and what’s best for the patient. Sometimes that’s a physician, sometimes it’s a nurse practitioner. It’s really about knowing what you don’t know, but knowing who/how to find out.

    • M Flynn

      Ahem. But the death rates didn’t begin to fall until AFTER anesthesia became a medical specialty…

      BTW, a 2nd-yr anesthesiology resident still has 3 more years of supervision ahead of him/her; your argument begins with a false premise. That being said, the 2nd-yr won’t be looking to be relieved at 3pm, to go home.

      • Anonymous

        1) If you look at the historical record, you will probably find that this coincided with the development of airway protection and non-volatile anesthetics. Ether and chloroform have nasty post-anesthesia repercussions, no matter who administers them.

        2) Staff nurses change shifts at 1500, CRNAs and anesthesiologists stay until the case is done.

        • Anonymous

          False CRNAs go home at 5 at the program I trained at and the residents took over for them…they never stayed until the case was done

          • stanley kristiansen

            Thats nice, the program I went to we stayed and residents would go home..depending on call rotation every 4th in house for us. 

  • http://CANDIDMDEXPSLAINSHIGHCOSTDECLININGQUALITYUSHEALTHCARE.COM Alan D. Cato MD

         Making a wrong diagnosis and subsequently choosing an
    ineffective or harmful therapy, is almost always due to the clinician’s not
    possessing sufficient physiological, pathological, or pharmacological knowledge
    base—or, in ignoring that knowledge base in his/her approach to the case. This
    should give us pause for reflection, given the increasing numbers of “physician
    extenders” (of all types), being employed as physician substitutes in health
    care delivery today. The formal medical science training of these individuals
    is shockingly disparate to the medical sciences education and residency
    specialty training of an MD— i.e., not even in the same ball park.  The formal medical science educations and
    clinical skills of NPs, physician assistants and nurse anesthetists are simply
    not commensurate with the task of practicing, unsupervised—or for serving as
    first contact care providers—for the evaluation of a patient’s presenting
    complaint.

           In the practice of medicine—simple presenting
    complaints and simple prescriptions—exist, only in the minds of “simple”
    clinicians.  The triaging of patients’
    signs and symptoms is the most important, difficult, and high-risk task in all
    of clinical practice, and success at it requires a physician to draw on his/her
    exhaustive education and training—more often than any other undertaking in
    medical practice—for differentiating the “routine”—from routine-mimicking life
    threatening catastrophes!

         There is a reason
    for the lengthy and grueling nature of the educational pathway to the M.D.
    degree. . —Alan D. Cato MD, F.A.A.F.P. (past) and author of The Medical Profession Is Dead and the Doctor
    Is “Critically ill!” (Oct.,
    2010)

       

    • http://twitter.com/mmacfn1 Mike MacKinnon

      Dr Cato

      Where is your evidence? Your statements are not consistant with any of the available evidence related to anesthesia mortality and provider type. In fact The argument that superior education and experience will always offer better outcomes is inconsistent with any available data, whether in reference to anesthesia care, obstetrical care, or many other medical and nonmedical activities within society. You may need to be an electrical engineer to design a television, but you don’t need to be one to fix one. This is born out by research as opposed to opinion.

    • stanley kristiansen

      Wow, I mean wow… not a single fact.  opinion is not evidence, I could just as easily say that any one who spouts such opinion as fact is clearly incapable making a realistic assessment of a patient and is not capable without a psych supervision.

    • Anonymous

      Last time I checked, it was nurses who run ED triage areas.

  • Anonymous

    Seems to me…
    Unsupervised anesthesia care by “any medical professional” is a threat to patient safety.Why are you picking the nursing profession? Just protecting your turf, huh?Duh!

    • Anonymous

      Hmmm….

      Are any of the MDAs here going to address Anesthesiologist Assistants?  Or how about the notion that Nursing Anesthesia is essentially the result of surgeons’ desire to focus solely on operating on the patient.  I’m just curious…

  • http://pulse.yahoo.com/_HYJWHVO6DBIRJO4QTZYEXGXNNA RJ

    Wow, as a recently minted board certified Anesthesiologist, coming from an training program with zero CRNA exposure I had little idea the threat mid-levels pose.  This article has been a real eye opener.  I was directed to this site by someone at work.  Up until now, I always viewed working with CRNAs as a cordial symbiotic affair.  I need to re-evaluate this attitude.  At my current gig we have SRNA’s rotate through.  In the interest of patient care, I have always been more than generous with my knowledge.  After reading posts from nurses in this thread, I now realize I am simply feeding the animal that wishes to bite my hands off.  I have resolved in the future to contribute as little as possible to their education and will do my best to convince complecent colleagues to do the same.  We cannot leave our future to the politicians.  Who trains the majority of CRNA’s?  Who runs the majority of Anesthesiology Dept?  ANESTHESIOLOGISTS.  The way I see it, all we have to do is STOP TRAINING THEM… yes even if it means making sacrifices with regards to the bottom line.  Things wont change overnight but we can start to stem the tide.  I will do my part.  I hope my fellow Anesthesiologists do the same.  Writing my check to the ASAPAC right after I get off the computer!    

    • Anonymous

      Want a suggestion? Try decaffeinated.

    • Luke .

      So, you are willing to sacrifice patient quality in order to protect your salary? A real good doctor you are.

    • Anonymous

      “I have always been more than generous with my knowledge.” 

      What? 

      This is exactly the kind of attitude consumers don’t need in our health care system. The “I’m better than you so shut up, sit down and speak when you are spoken to.” These prima donnas may have the “knowledge” that they boast about, maybe, but consumers have the money. Consumers pay the bill. Consumers can shut off their water at a moment’s notice. Consumers are beginning to insist that their insurance companies to be more discerning about docs with an attitude. The biggest threat to any scam? An educated consumer! 

      • http://pulse.yahoo.com/_HYJWHVO6DBIRJO4QTZYEXGXNNA RJ

        ‘Consumers are beginning to insist that their insurance companies to be more discerning about docs with an attitude.’
        Dave, when my dad needed pancreatic surgery, in addition to doing our due diligence on a surgeon we also made sure the anesthesia provider was well respected, experienced, and extensively trained.  Spoke to several colleagues through the grapevine for recommendations.  Although the hospital employed CRNAs in an ACT model, the’ goto ‘team’ I was told was a solo anesthesiologist.  You can argue about the economics and how there aren’t enough anesthesiologists to go around, but I would not wish any less for one of your loved ones.  As an anesthesiologist, I contend there is no better educated consumer than I.  Btw, not sure if the insurance company checked out if the docs we chose had theproper attitude… will need to get back to you on that one.   

        • Anonymous

          Well, it must be nice to have an inside connection, huh? “Spoke to several colleagues through the grapevine for recommendations.” How nice! It’s really great that you had the ability to hand pick your designer team, huh? Gee, it’s a shame not all of us are big shots in the health care industry, huh? In fact, 50 million Americans never get a chance to have anything they can call their own “goto team”. Why? Because those 50 million aren’t “connected” like you. They can even afford to even get pain medicine for their pancreatic cancer. Most of those 50 million with cancer know they can’t afford health care insurance and that they will die and only want to make their exit without so much pain. Oh, by the way, did I mention the 25 million additional folks that are underinsured? What about them Mr. Colleague? Any chance we can give them a little assurance that they’ll get those pain meds. The system we have today is broken beyond help! The AMA, AHIP and PhRMA have a death grip on my Congressman and my Senator and until some hero comes along to break the profit cycle for Congress, it’s going to stay the same. The payola is just too darn good! One fourth of Americans either have no insurance or don’t have insurance that works when they need it. Then, there are people like you. People with inside connections! 

          • http://pulse.yahoo.com/_HYJWHVO6DBIRJO4QTZYEXGXNNA RJ

            Why shouldn’t we get to pick our provider?? In fact YOU were the one harping about the virtues of an ‘educated consumer’ in your previous post. Those were your EXACT words–how quickly we forget!  Please don’t be so dramatic.  ANYONE off the street can receive government aid.  How do I know???  There is a help desk in my hospital lobby reminding me of this fact everyday.  It just so happens I provide high quality compassionate care to those unable to afford healthcare day in and day out– all of which at a fraction of actual cost.  I don’t disagree we have a broken system. Reform is inevitable at this rate. But at what cost??  I think even you will agree, the poverty stricken masses deserve care of the highest standards and not be pawned off to lesser providers. 

          • Anonymous

            Talking to you is like talking to a drug dealer or a pimp trying to protect his turf. You see the Occupy Wall Street movement? Well the Occupy Health Care movement is on the list! One-quarter of Americans are uninsured or underinsured. That number keeps growing every day. Get it? Our current system can not be sustained. The sooner you make health care work as well for the consumer as it currently does for you and your colleagues, the better things will be for everyone. Keep stalling and buying time for the current broken fee-for-service model, keep milking the cow, and guess what? An Occupy crowd will soon be knocking on your hospital doors and pushing their way in to set up their tents!

  • Stephen Ferrara

    You are changing your attitude based on a few posts on a blog? This seems incredibly short-sided and I only hope thats not how you objectively evaluate all evidence.  

    • http://pulse.yahoo.com/_HYJWHVO6DBIRJO4QTZYEXGXNNA RJ

      No evidence need to be ‘evaluated’ here.  This is not a crime scene or science
      experiment.  Blog or not, my attitude is
      what it is because the FACTS can no longer be ignored.

       

      Fact: There are nurses out there who want to play doctor

      Fact: They are represented by a NATIONAL association that
      lobbies endlessly to this end

      Fact: The recent CMS rule change initiative spells out how
      urgent this issue has become. 

      Fact: I will do my part (however small) to oppose this trend and convince others to do so as well.  I will start by minimizing my involvement with SRNAs.      

      • stanley kristiansen

        Fact anesthesia has been a nursing specialty for over 100 years, therfore using your “logic”
        1. doctors are attempting to be nurses, fact
        2. fact there is a national and state associations who wish to promote the medical takeover of a nursing specialty.
        3. fact  the CMS change threatens the income of these nurse wannabes
        4. fact your part will be small.
        Wow it is weird looking through the world out of ignorent hostility, how do you do it?

        • http://www.facebook.com/people/Ailan-Medici/1409476759 Ailan Medici

          Stanley, your responses to posters whom you disagree with are so silly, that you are doing a disservice to the profession you are trying to defend.  Presenting your point of view with sarcasm or snarkiness will not win over anybody (i.e. laypeople, patients) who read this blog to be better informed.

          • stanley kristiansen

            oh I am sorry I will just note the MD snarkiness, please allow me to apologize if my pointing out the inannity and ignorence of the aforementioned statments upset you.

        • http://pulse.yahoo.com/_HYJWHVO6DBIRJO4QTZYEXGXNNA RJ

          Wannabe nurses??  Let’s
          get real here.  How many kids aspire to
          be nurses when they grow up?  I am not
          knocking the profession… it is what it is.  By your twisted logic, I would then reason since barbers performed
          surgery hundreds of years ago… somehow surgeons are trying to be barbers!  How
          ridiculous is that? 
           

          Stanley, you are so darn transparent. 
          Look, it’s not my fault you couldn’t cut it as a pre-med.  I understand your frustration as it will
          probably hunt you for the rest of your life. 
          May I suggest non-traditional medical school application?  No wait… of course you wouldn’t dare selling
          out.  That would mean you’d have to ace a
          legit basic science curriculum and actually score well on the MCAT!  Much easier to just apply to your local community
          college nursing program.  Bad memories I know. 

           

          Like I said previously, I work cordially everyday with
          CRNA/SRNAs and will continue to do so.  I
          just won’t contribute to their education and clinical development as I had
          previously dedicated myself.  At every opportunity
          I will discuss this issue with my colleagues. 
          If it were just you and a few others out there who feel this way I would
          simply dismiss you guys as outliers.  Unfortunately, I now realize the AANA apparently is the one spearheading this movement.

           

          My part may be small now, but one has to start somewhere.  The current group of young anesthesiologists
          are a new breed: bright, motivated, and hard working.  Rest assured I will get involved wherever I can
          and in short order my influence will grow.  Please excuse my ’ignorant hostility’…

          • Anonymous

            Just because some of us realize that pre-med/medical school isn’t for him/her (including myself) and opt for nursing (or another health care discipline) doesn’t make us failures, so there’s no need for rudeness. We became nurses because we wanted to, NOT because we couldn’t get into medical school. As far as CRNA/SRNA education and declining to assist in their education, now you’re just being petty.

          • http://pulse.yahoo.com/_HYJWHVO6DBIRJO4QTZYEXGXNNA RJ

            laura, i don’t mean to be rude but judging from his posts stanley apparently has a knack for bringing out the worst in people. hard to imagine he is any different in real life. fwiw, would you please answer me this question: why would anyone choose to become a nurse if all they aspire to do is practice independent medicine? and do spare me the sob stories. i had to overcome many hurdles to achieve my dream. my parents were blue collar folk who never went to college. was told i had a learning disability in grade school. my family survived many years on my mom’s meager 25k salary. i put myself through college working 2 jobs. mac and cheese was my staple up until recently. if someone wants to practice medicine, go to medical school. too much school/ training/ sacrifice you say? not for everyone? you’re absolutely right. i’m sorry but refusing to train what i consider ungrateful/ backstabbing so called colleagues is not petty but plain common sense. why help train today’s CRNAs when tomorrow all they want to do is fight to legislate your obsolescence!? trust me, i appreciate the current ACT model but can no longer continue in the current environment. wish you and your family a happy thanksgiving.

          • Anonymous

            I strongly suggest that you read the Nurse Practice act in the state where you. There are aspects of nursing practice that are interdependent with medicine, but there are other aspects that are independent. I too worked my way through school: as an LVN to complete a community college RN program, then a working RN as I completed an RN-BSN program, both while supporting a family. While I understand your antipathy towards advanced practice nurses, how many of them do you really know as individuals and how much of this antipathy has been created by your professional organizations vs personal experience?

          • stanley kristiansen

            Well RJ my mother was a nurse and my father a CRNA, sort of a tradition I do not want to practice medicine independntly, just nursing.  Remember anesthesia has long ben recognized as a field of nursing.
            I do not desire the elimination of anesthesiologists, I have found my interactions with most quite pleasent, I have learned much and taught much (mostly regional and practical tidbits you know).  I could not teach them medicine but they have taught me a fair amount.  Really the status quo has been independant practice for CRNA’s the ones who really want to change things are the ASA.
            BTW most people find me pleasent, but most do not talk down to me or call me a wanna be doctor.  I feel no need to protect the ego of those who throw stones and when it is thrown back cry mommie mommie the nurse was mean to me.

      • Anonymous

         ”Doctor” is a TITLE, not an OCCUPATION. Your occupation is physician. You rebel at addressing doctorally prepared nurses as “doctor,” but I bet you have NO problem addressing a PhD in chemistry or literature as “doctor.”

      • http://www.facebook.com/people/Earl-Mueller/100002595814885 Earl Mueller

        RJ…  Here, Here!!  You said it, minimize you’re involvement with SRNA’s.  Not only will that “show ‘em” you mean business, but you will also get to sit on your own stool, do your own case, and bill for that one case at a time to medicare or whoever.  Good to know that your financial plan is willing to take that reduction in salary.  I commend you for stepping up to the plate and make exactly what work you put in.  Too bad that strategy will back fire if more of your collegues would do the same…. not enough MDA’s to do all the cases in America to fill the shortage that will incur.  Perhaps ASA can lobby for increased federal funds to increase MDA training slots in medical centers to fill the gap.  Either way, I commend you for getting those pesky SRNA’s and CRNA’s out of  your way… after all, what the hell do they know…. their just a nurse.  ;-)

        • http://pulse.yahoo.com/_HYJWHVO6DBIRJO4QTZYEXGXNNA RJ

          Earl, I appreciate your concern for my financial well being but you’re grossly missing my point. I have nothing against working with nurses, as I had previously stated I embrace the ACT model. Nurses proclaiming equivalence that’s another matter. When a srna is assigned to me they will receive just enough medical knowledge to be safe in the surgical environment and little technical training beyond putting in an IV. I suspect most of my partners at work will feel the same way once they read some of the comments here. Unfortunately many are in the dark with regard to this issue… especially in the big city environment I work in.  However, the word will spread. If only a fraction of my colleagues out there follow my suggestions, the notion of equivalence will be even more ludicrous than they are now regardless of how many phony studies the AANA comes out with. Sure there are well trained military crnas or the rural crnas that ‘does it all’ but they will be the exception. Again, just to be clear: to me this is not about working harder or making less; what I do object to is the absurd assertions of equivalence by people who only have a fraction of my training.

  • http://twitter.com/#!/CloseCall_MD Close Call

    I’m still really confused.  It’s too much for my old mind to process.  

    Who would be comfortable with a newly trained CRNA right out of training to practice independently without restriction on their loved one?   Because that’s what we’re talking about here.  It’s not about the military CRNA with four decades experience – someone who has taken care of any complication and could deliver a baby while on horseback using just a wooden spoon if asked to do so.  It’s about that fresh, baby faced CRNA with maybe 1500-2500 hours of clinical care under their belt (from the AANA).   Compared to that fresh faced MDA with maybe 11, 000 hours of clinical care experience (not counting med school).  Is that a negligible difference? 

    Let me make a insane proposal: allow CRNA’s to go through anesthesiology residency after they finish their didactics.   That way they can get more experience in a supervised environment (similar to MDs and DOs).  Everyone wins!

    • http://twitter.com/mmacfn1 Mike MacKinnon

      Close

      CRNAs have always been able to practice autonomously as a sole anesthesia provider right out of school in every state in the union. The removal of the CMS rule would only serve to remove the requirement (COP) for hospitals to bill medicare part A. Though this requirement is called “supervision” it does not require an anesthesiologist and has nothing to do with the layman term “supervision” but is a billing term. In other-words it is simply a removal of billing terminology as the practice already happens in every state.

      Hope this helps to clarify the real issue here.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        Yes, the real issue is billing, because first will be Medicaid, which will only pay for CRNA and not MDA. Next, those “affordable, consumer-driven” insurance plans will also only pay for CRNA for their members. Medicare will follow, perhaps with carve outs for complex cases, just to make administration even more burdensome than it already is. Before long, the only folks able to choose an MDA will be those that are wealthy enough.
        And this is what is at stake with midwife vs. OB and MD vs. NP in PC and probably more and more medical care, which will become “separate but equal”, according to studies, of course.

      • http://twitter.com/#!/CloseCall_MD Close Call

        Mike, I’m sorry.  I’m just more confused now.  

        So every CRNA who graduates right now can practice autonomously in every state without needing an anesthesiologist within 100 miles of them?  The “supervision” part is just a technicality and doesn’t really mean that the new CRNA has some sort of backup?  Is this hubub really about billing?  Why would it matter to the CRNA how the hospital bills?  Unless this was really so that the CRNA could get paid more… then it makes more sense.  

        The next question would be: Why in the world would anyone want someone with just 2500 hours of training (and no one for backup) when you could have someone with 11000 hours of training?  It’s one thing if patients had a choice.  But 1) most patients aren’t savvy enough to ask about the training discrepancy.  2) patients coming through the ED have no choice in this preference and 3) let’s say this billing issue is worked out – and CRNAs could bill without having an MDA “supervise”… can I look forward to my ACO employing only CRNAs from now on… or my insurance provider (i.e. Medicare) only paying for CRNAs and not for an MDA?  Where is the choice in that?

        • stanley kristiansen

          you are correct sir in your understanding as it relates to CMS.  States have determine the supervision issue, some states just say supervision some use the word direction and some use the word colaberattion.  Really it is about who signs the chart insofar the concern over CMS decisions.  In all states it can be the surgeon who sign, tell me how does this make you safer?  How does signing a chart make anyone safer?

          • Guest

            Signing the chart makes nobody any safer. Having an anesthesiologist available to manage the case is the lifesaving part.  Signing, billing, who cares?  I want an anesthesiologist performing my case (and that’s what I get, I don’t thing that supervising 4 CRNA is safe at all).

  • Phooey F

    It is physician assistant and not physician’s assistant.

  • Anonymous

    Apparently accurate information and published research don’t fit into Dr. Sibert’s arguments about physician supervision of nurse anesthetists. Following are facts that can be checked simply by looking them up:
     With regard to the recently issued new rules concerning conditions of participation, CMS left in place a rule that requires nurse anesthetists to be supervised by physicians, but that provides states a mechanism for opting out of this requirement. To date, 16 states have.
     To be perfectly clear, federal laws and regulations do not require nurse anesthetists to be supervised by anesthesiologists. To assert otherwise is patently incorrect.
     President Bill Clinton’s mother was, indeed, a CRNA. However, the opt-out rule was signed into law by President George W. Bush during his first term in office [66 FR 56762-56769]. President Bush’s mother was not a CRNA.
     The anesthesia care team model is far from the most cost-effective anesthesia delivery model. According to a study conducted by Virginia-based The Lewin Group and published in the May/June 2010 issue of the Journal of Nursing Economic$, the most cost effective model of anesthesia delivery is a CRNA acting as the sole anesthesia provider. The study, titled “Cost Effectiveness Analysis of Anesthesia Providers,” considered the different anesthesia delivery models in use in the United States today, including CRNAs acting solo, physician anesthesiologists acting solo, and various models in which a single anesthesiologist directs or supervises one to six CRNAs.  The results show that CRNAs acting as the sole anesthesia provider cost 25 percent less than the second lowest cost model. On the other end of the cost scale, the model in which one anesthesiologist supervises one CRNA is the least cost efficient model.  The study’s authors also completed a thorough review of the literature that compares the quality of anesthesia service by provider type or delivery model.  This review of published studies shows that there are no measurable differences in quality of care between CRNAs and anesthesiologists or by delivery model. And, in the name of transparency, it is important to note that the study was supported by the AANA Foundation, but that was where the Foundation’s involvement in the research or publication of the results ended.
     Two months later, in the August issue of Health Affairs, a national study conducted by RTI International confirmed that there are no differences in patient outcomes when anesthesia services  are provided  by Certified Registered Nurse Anesthetists (CRNAs), physician anesthesiologists, or CRNAs supervised by physicians.  The study, titled “No Harm Found When Nurse Anesthetists Work Without Supervision by Physicians,” compared patient outcomes in states where the supervision requirement is in place with patient outcomes in the 14 states that had opted out of the requirement between 2001 and 2005, and found that patient outcomes did not differ. The researchers concluded that “Based on these findings we recommend that CMS repeal the supervision rule.” Again, it is important to note that the study was supported by the AANA Foundation, but that was where the Foundation’s involvement in the research or publication of the results ended.
    Then, in October 2010, landmark findings from the Institute of Medicine (IOM) asserted that expanding the role of nurses in the U.S. healthcare system will help meet the growing demand for medical services. Titled “The Future of Nursing: Leading Change, Advancing Health,” the IOM report urged policymakers to remove policy barriers that hinder nurses—particularly advanced practice registered nurses such as CRNAs—from practicing to the full extent of their education and training. The IOM report was the work of the IOM’s committee on the Robert Wood Johnson Foundation (RWJF) Initiative on the Future of Nursing, which consists of doctors, nurses, academicians, and other healthcare representatives.

    With regard to anesthesia in the military, CRNAs have been the main provider of anesthesia care to men and women serving in the military since World War I. True stories: When U.S. Army Private Jessica Lynch was freed from her Iraqi captors in a daring rescue mission in 2003, it was a special ops nurse anesthetist carrying medical supplies and a weapon who accompanied the team, not an anesthesiologist. In 2006, when Bob Woodruff was critically wounded covering the war in Iraq, it was a CRNA, not an anesthesiologist, who flew into the combat zone and airlifted the reporter to safety. And when President George H.W. Bush attended a drug summit in Columbia in 1990, a ground medical team was present to support the president in case of a terrorist attack. That team was made up of two surgeons and a CRNA; an anesthesiologist stayed safely on board the U.S.S. Nassau off the coast, not exactly “immediately accessible” should something have happened.  In all of these cases, either it was deemed unnecessary to have an anesthesiologist present, or an anesthesiologist couldn’t be found to volunteer for the mission, but the bottom line was an anesthesiologist wasn’t there. Dr. Sibert’s depiction of CRNAs in the military is not only offensive and inappropriate, it’s grossly inaccurate.
     
    Finally, on the topic of pain management, procedures such as epidurals, nerve blocks, and other techniques are as much a part of a CRNA’s education and training as they are an anesthesiologist’s. In fact, the majority of obstetrical anesthesia, including epidurals, given in this country is administered by nurse anesthetists. Seriously, at 2 a.m. when a CRNA is on OB call and an epidural needs to be placed, how often does it occur that a physician of any kind is standing looking over the CRNA’s shoulder to make sure this “complex” procedure is done correctly?
     
    The main focus of CRNAs is to ensure all patients access to safe, cost-effective anesthesia care, and it  has been shown over and again—in daily practice and through research—that this is exactly what is happening year in and year out.

    Debra Pecka Malina, DNSc, MBA, CRNA
    President, American Association of Nurse Anesthetists
    American Association of Nurse Anesthetists

    • Anonymous

      Now don’t you think there is a little issue of conflict of interest when these studies are sponsored by the AANA.  Seriously, this is actually laughable.   What type of studies were these?  Were they blinded?  Probably not.  I’m willing to bet that they were conducted by collecting retroactive data.  Which you should know (i hope) is the worst type of study.  Also, what type of info was looked at to collect this data?  One telling quote you mentioned, however, that I completely agree with was  – ““The Future of Nursing: Leading Change, Advancing Health,” the IOM
      report urged policymakers to remove policy barriers that hinder
      nurses—particularly advanced practice registered nurses such as
      CRNAs—from practicing to the full extent of their education and training”  The key being ‘from practicing to the full extent of their education and training’.  The training is just not adequate to practice unsupervised.  I have worked at institutions that train SRNA’s and can tell you firsthand that they did not learn blocks.  I currently work with CRNA’s and not a single one (out of fourteen) know how to perform a nerve block.  They do not place epidurals either.  Its not their fault, the training was just not appropriate to do these procedures.

    • Guest

      Why in the world would a patient EVER want a burse (CRNA) performing their anesthesia instead of an anesthesiologist?  The difference in training is stagering.  AANA President:  why has every anesthesiologist had to “bail out” a CRNA at one time or another?  Simple: because CRNA aren’t anesthesiologists.  And you think that a CRNA cn be properly supervise by anyon other than an anesthesiologist?   Like a surgern?  Please….Oh I guess that you believe that unsupervised CRNA practice is safe; it’s  certianly not.

      • Anonymous

        A burse? I’d never want a burse performing anesthesia on me. I don’t even know what a burse is!

  • Anonymous

    Hahah….the AANA president…Debra nice spin work

    1)  CRNAs have to be supervised by a physician.  Anesthesiologist are physicians trained to deliver anesthesia and care for patients in the peri-operative setting thus we are the physicians supervising CRNAs.  Would not be wise to have cardiologist supervise a CRNA.

    2) opt out rule was signed into law by president Gearge W Bush.  
     On January 20, 2001, the incoming George W. Bush Administration announced a 60-day blanket morato- rium on implementation of all regulations published in the final days of the Clinton Administration that had not yet taken effect which included the opt out rule
    With the inauguration of President Bill Clinton in 1993, healthcare reform became a priority of the administration, and part of the reform included legislation that would have an impact on the practice of nurse anesthetists. On April 25, 1994, Representative Mike Kreidler (D-WA) introduced H.R. 4291 that sought to eliminate 3 existing Medicare barriers to the practice of Certified Registered Nurse Anesthetists (CRNAs). One of these was Medicare’s hospital and ambulatory surgical center rule that CRNAs had to be supervised by a physician; Kreidler’s bill sought to defer the matter to the states instead. A few months later Senator Kent Conrad (D-ND) introduced S. 2310, the companion bill to H.R. 4291. The American Association of Nurse Anesthetists (AANA) began a public relations campaign that emphasized grassroots lobbying support for the bills—an effort that would continue throughout the coming years.
    So clearly it was the clinton administration who was behind the whole opt out regulations and you are correct his mom was a CRNA

    3)  Dont have time to dive into the articles you mentioned…any individual with a hint of statistical knowledge can look at those articles and literally laugh and throw them in the trash

    4) “Finally, on the topic of pain management, procedures such as epidurals, nerve blocks, and other techniques are as much a part of a CRNA’s education and training as they are an anesthesiologist’s”  Debra you were doing alright until this sentence.  You clearly have no idea what is actually being taught across the country.  Student CRNA’s I agree are being taught epidurals…but I can tell you from first hand experience as can thousands of others including student CRNAs…they are not being adequately taught nerve blocks, CVLs, hearts, major vascular cases, complex peds, to work independently.  They get numbers by watching residents or working on simulators.  They are not safe to practice independently.  Let me guess…were is the evidence?   If you find an IRB that will allow a study to be set up that allows newly minted CRNAs to work independently doing all cases and procedures let me know because I am sure I could find many interested anesthesiologist to go head to head with them.  

    5) Your political spin and agenda is dangerous

  • Anonymous

    It’s amusing to read fearful post coming from corrupt providers that see the handwriting on the wall. They are so fearful that their status quo health care system, the same broken system that only benefits them, the health care insurance companies and Big Pharma, is slowly crumbling and coming to an end. ACOs are buying up private practices in record numbers all across America. The single-doctor private practice model will soon be history. Wellness and good outcomes will soon replace our current and failed fee-for-service model and beaten-down consumers will flock to “big box” health care centers in droves. The party is over for you small profit driven maniacs. The abuse of our Medicare consumers and the abuse of health care consumers in general must end. We need to put consumers on the top rung instead of the bottom. Many local hospitals in my region already have the ACO model in place and they continue to buyout the smaller providers. They are just waiting to announce their grand opening. Many critics will say, “You’ll be sorry if the ACOs take over!” They say, “Quality will suffer!” To these critics I say, providers had your chance to make things better for the consumer. The insurance companies had their chance too. Big Pharma had their chance to make their products more affordable. Guess what? All three kept profits as their top priority and kept the consumer at the bottom. I say, anything is better that what we have today. Spending 18 percent of GDP on health care and we rank 37th worldwide with 50 million plus uninsured and another 25 million underinsured? What’s so good about that? If anything, we need more nurses and less doctors, at least in primary care and in anesthesia care. 

    • Anonymous

      It is amusing that you think that a ACOs are the answer.  Do you think ACOs that are buying up PP groups in record numbers is because they are going to make healthcare cheaper and a higher quality…sorry dave it is so it insures that they can get a bigger piece of the medicare pie.  Trust me this will not make it cheaper…just like HMO, PPO, etc…did not make anything cheaper for anyone now like they were suppose to decades ago

      • Anonymous

        The major difference between the ACO model and “just like HMO, PPO, etc…”? 

        The ACO model pays their “employees” a “salary”.

        The failed fee-for-service model is tossed out the window. Fee-for-service rewards volume and sickness. The ACO model rewards wellness and good outcomes. Unlike in today’s broken system where a filled waiting room means big profits. The ACO does best when there’s nobody in the waiting room and the professionals still get paid. All the “so-called” brains we have in the AMA and AHIP and PhRMA and nobody could figure this out? What a bunch of complete morons?

        • Anonymous

          Dave, what happens when a hospital gets a bundled package payment that does not cover the cost of the patients care?  Do you really think that society is going to be ok with hospitals saying sorry there is no more money left in your bundled payment to continue your care…nope and the payments will increase based on that pressure.  The absolute only way to change the continued increased cost of healthcare is to have a single payer system for everyone.  Would this decrease the cost and limit care…yes…but the majority will similar care.  ACOs will not work I promise you…but they only way to find out is to spend billions to establish ACOs and give them a shot I guess.

          • davemills555

            As long as America’s hospitals and their lobby group, the AHA, continue to wuss out and refuse to fight mandated emergency room care as aggressively as Republican ATs in red states are fighting the individual mandate, hospital stakeholders will be massive losers. The only thing I can figure is that hospitals love the abuse. It’s amazing that some Republicans actually believe that the uninsured don’t get health care when, in truth, they get the best and most expensive health care available. Are Republicans that stupid? Apparently! 

            Regarding ACOs, read and weep…http://www.healthreformwatch.com/category/accountable-care-organization/page/2/

  • http://www.facebook.com/people/Earl-Mueller/100002595814885 Earl Mueller

    Mr. Ridics,  Could you please site the statute that requires CRNA’s to be supervised by an “Anesthesiologist”.  I can’t seem to find it.  Yes, CRNA’s are to practice under the supervision of a physician, not specifically an anesthesiologist.  Hence the reason CRNA’s are the only “anesthesia” provider in most cases in America today.  The Gastroenterologist doing the EGD or Colon, Plastic Surgeon doing what ever case, heck, even oral surgeon doing a case…. those are all physicians.  Do they know a hill of beans of about anesthesia??  No they do not.  Furthermore, the legality of “captain of the ship” has fallen by the wayside, hence can no longer be used by MDA’s to purport liability to surgeons for care given by the CRNA.  If that were the case, I would not need to cover liability insurance for my own practice, correct??  So obviously there is a surgeon or MD involved somewhere with the CRNA… because after all, why would a CRNA even be there if it were not for the MD doing “something” to a patient that needs them to remain still, be free from pain, etc.  We as CRNA’s independant or not are not simply going to go around knocking people out or sedating patients just for giggles.  So, seriously, please site the federal statute that say’s an Anesthesiologist must be present for supervision of all CRNA’s, that only applies in areas of the VA health system.
     
    Good day and Happy Turkey’s to all….

    • Anonymous

      Earl not what I said….I said that a physician must supervise an anesthesia nurse (CRNA)…why would you have a cardiologist, dermatologist be the supervising physician when they know nothing about anesthesia when you could have a anesthesiologist who is a physician supervise the anesthesia nurse…just seems logical to me.  Again never mentioned anything about “captain of the ship”.  I guess my question to you would be if your family member was having surgery and something went wrong would you rather have a physician anesthesiologist for back-up or a physician gastroenterologist…I think I know the answer 99% of the population would have.  

      • Anonymous

        Supervision is not for CRNA practice. Supervision is for reimbursement of Medicare part A (facility charges) only. Quit twisting reality.

        • Guest

          Supervision is for patient safety!  Quit trying to put patients at risk.

        • Anonymous

          Debra, AANA President

          Supervision is for CRNA practice, the vast majority of CRNA’s are supervise and should be.  Ms AANA President, please post requirements for your student in regards to major vascular, hearts, regional etc for all to see.  Also when you post these numbers please explain to everyone that when the requirement states management of regional procedures it does not equate to performance of those particular procedures.  I can tell you for a fact I have had student anesthesia nurses when I was a resident watch me perform carotid endarterectomies, abdominal aortic aneurysm repairs, and heart surgeries etc just so they could record it so they could graduate.  Also they just have to manage blocks and watch physicians place them.  How does the equate to a practitioner that is able to graduate and practice independently….it clearly does not.  Anesthesia nurses should be supervised by an anesthesiologist.

  • http://www.facebook.com/people/Earl-Mueller/100002595814885 Earl Mueller

    Ever so cost concious European collegues do not embrace it because in Europe’s socialized medical world, Anesthesiologists a.k.a. “Anesthetists” (England) are paid significantly lower salary than here in the U.S.  Furthermore, are viewed much more as a “technician” rather than on par full physician.  Job satisfaction is an issue in the field in England…if it remains so, you just might see the socialized healthcare industry there go exactly the way it is here.

    • Anonymous

      Hahaha…earl you have proven that you know very little with the above statement…just see snozcumber’s post above…you would be correct though that the difference between the two systems is likely secondary to the economical difference between the two systems.  

  • Anonymous

    You will find anaesthetists ” rule the theatre roost ” in England, Australia and New Zealand (countries I have worked in ) .No kow towing to surgeons. Anaesthetists run the Intensive Care Units , manage pain clinics and are available for all emergency situations.  Anaesthetists are on the exact same  pay scale as their collegues    (fellow physicians)  working  within the public healthcare  setting.  ie surgeons,oncologists, urologists etc.They are highly regarded and valued for their skills as Consultant Medical  Specialists/Physicians.

  • http://www.facebook.com/armygas Michael Bentley

    If safety was the issue, why did the ASA President in 2007 suggest a 10:1 ratio?  How can an anesthesiologist be in 10 places at once?  Again I will post what I wrote and wait for comments:

    Regardless of the anesthesia provider, anesthesia is safe.  In fact here is a bit of information taken from a Harvard lecture on Anesthesia Safety:Anesthesia mortality has fallenfrom 1/ 3,000 in 1985to 1/ 30,000 or 1/300,000in 1996 (and has remained there)1/295,118 = 6 sigmaPlease note that this is 15 years ago.  It is commonly accepted by many authorities to be over 1 in 400,000 today.  Anesthesia is six sigma regardless of the provider.  Also,I would like to bring to your attention comments made by Mark Lema, MD, PhD who was President of the ASA in 2007.  He gave a lecture at the ASA Practice Management Conference titled “21st Century Anesthesiology – Preparing for the Future Paradigm”.  He first begins by detailing the shortage of providers by stating that the expansion of anesthesia services into offsite/unusual anesthetizing locations creates greater demand with reduced efficiency.  He then admits that the Pain Medicine specialty has further depleted MD Anesthetists.  In the next slide he expresses the financial motive for the argument portrayed in the editorial written by Dr. Seibert.  At this conference he admits Value=quality/cost + access.  He states “Society will solve the anesthesia provider shortage/high cost of care by allowing others to partake in anesthesia care to drive down prices and improve access.”  So as you can clearly see this is a financial turf war because safety has not been mentioned by Dr. Lema at this conference to this point.  He then shows a slide where anesthesiologists are the 4th highest paid specialty behind radiology, orthopedics, and gastroenterology.  Still no mention of safety to this point, only money.  The next slide is titled “Telltale signs that we may be on a salary bubble”…… still about money, not safety.  The “money” section ends with a slide titled “poachers and dabblers” in other words, “threats” to anesthesiology compensation.  Now I can provide this slide set to anyone please email me at armygas@gmail.com and I will gladly send it to you.  Dr. Lema then reviews U.S. efficiency in the world in delivering healthcare in which we rank last compared to the other industrialized nations.  Finally he gets to the “Future of Anesthesia Practice”.  In this section he reviews the findings of MF Weiss given in The Resource #61 7-8/06.  In this section there is a slide that gives these two quotes, “… payor battleground battleground…they are price sensitive, not quality sensitive… genetically predisposed to go with the CRNA [cheaper]”….. “CRNA practice is here to stay. And the trend is toward independent practice practice…”This is very interesting.  The word “quality” is used but not “safety”.  Why?  Because safety is not the issue.  Nurse Anesthetists have delivered care for what now 150 years?  The issue of safety is the same argument used in 1921 (I can send you that article as well…. interesting that the debate today is the same as it was in 1921. Dr. Lema concludes his speech by telling the forum how to plan for future changes in Anesthesiology.  Please note these statements in particular:  1.”We must be both medically and financially prepared to expand our ACT supervision to an ICU-type medical direction (10:1) using CSNs along with CRNAs” and 2. “Independent Practice for CRNAs is a very likely prospect to be promoted by AHA and Hospital CEOs to lower costs and ‘expand’the workforce as access to care diminishes. We must factor this possibility into our plans to be both competitive and cost-effective.”Where is the mention of safety?  There isn’t because it isn’t the issue, money is…..Safety FINALLY comes up in the talk and he presents a slide which shows Anesthesia safety as 1:300,000 and “best in class”.  There is no differentiation of provider type.  There is a very large admission by Dr. Lema that Safety research is lacking and difficult.  He states that the plural of ANECDOTE is not DATA and that GOOD studies are needed.  (but that will be hard to do if you need a sample size of 3,000,000 based upon the effect size).  He makes this statement: “Research in outcomes and safety are needed to show our value to patients, colleagues and payers comparing us with both non-MD providers (CRNAs) and non-anesthesiology MDs (ICU/ER).”  It is of note that he felt the need to bold the words “outcomes and safety” and “value”.  I would speculate that value was the key at that meeting. Again this is a turf war about money… that is it.Lema then quotes Dr. Reves: “Our lackluster research effort must improve for a field with as many bright people as we have in it.It must improve for a specialty as old and mature as we now are. It must improve if we wish to advance anesthesiology. It must improve if we wish to sit at the table as peers with our academic colleagues in the halls of academe.……for if not, I fear a future where anesthesiology , will be viewed merely as a necessary, but only a technical specialty, irrelevant to mainstream medicine.medicine.”So again, this is about money not safety 

    Any comments?

  • Anonymous

      Michael-
      
       You have made some good points, but it is difficult (if not impossible) to comment on a lecture without the full presentation in addition to the added interpretation of the lecturer himself.  Also, one must remember that Dr. Lema is an academic who gave this talk over 4 years ago.  The ASA’s general stance is expanding the role of the anesthesiologist to all arenas of perioperative care: ICU, chronic and acute pain, preop clinics, OR adminstration and more.  They believe that the anesthesiologist should be a perioperative physician.  Implicit in their argument is that there are not enough anesthesiologists to meet this demand.  With this in mind, they have fully embraced the ACT model.  Some like Dr. Lema have taken it even a step further and suggested managing OR’s like ICU’s (thus the 10:1 supervision).  Others have gone even beyond that to postulate remote consulting (i.e. telemedicine for anesthesia).
       Cost is certainly a big factor (our health care system and country are broke), but I do not think Lema believes it is the only factor.  If he didn’t think his model was safe and cost-effective, he would never advocate for it.  I also think that “safety” is implied in “quality.”  How can you deliver quality care that isn’t safe?   So I believe the focus of the lecture was to outline a  cost-effective AND high-quality (i.e. safe) model.  Below are the words of Dr. Warner who succeeded Lema as ASA president.  

    “I believe that all people in this country who undergo sedation in which there is risk of loss of consciousness or airway compromise, or who require general or regional anesthesia, should have anesthesiologists involved in oversight of their preoperative assessment and treatment, intraoperative care, and postoperative management. However, I also believe that the provision of this care does not require all patients to receive one-on-one administration of the care by anesthesiologists.”

      I imagine that Lema feels the same as Warner: it is a matter of safety and cost.  I’m not saying I necessarily agree with Lema, but my interpretation differs from yours.

  • Anonymous

    I say, the best suggestion on here is to return to the days when surgery was performed by the local barber in the corner barber shop. I understand they always had an ample supply of chloroform! Best of all, anyone could afford surgery at the barber shop because it wasn’t any more expensive than a shave and a haircut! Two-bits!

  • Anonymous

    Anesthesia? For goodness sake, there are people within the 50 million uninsured and 25 million more who are underinsured who would simply love to have the cancer operation they need by using a lousy bottle of whiskey and a hunk of leather to bite down on as there sole source anesthesia. However, if it’s up to the AMA and AHIP and Big PhRMA, they ain’t even getting that! In today’s profit driven health care system, money talks and BS walks! What these professional morons don’t quite get is that the cows teats are drying up. You’ve milked the animal for far too long and there’s no more milk!

  • davemills555

    RE: http://capsules.kaiserhealthnews.org/index.php/2011/12/acos-are-bursting-out-all-over/

    The silent majority is waking up and they are voting with their feet. Now, if only WalMart would form an ACO!

  • Anonymous

    Dr. Silbert,
    There is an abundance of evidence in the literature supporting the history of safe and very effective care delivered by autonomous Advanced Practice Nurses (APNs).  And if you do a top-notch lit review, you will discover what the AMA has always been aware of:  there has never been a single study, nor does there exist any actuarial data to suggest or support your opinion that APNs are not safe and effective health care providers when we deliver care within our scope of practice.  In most jurisdictions in this country, Dr. Silbert, Nurse Practitioners (NPs) have been practicing as fully autonomous and independently licensed and insured practitioners for more than a half century, and not, as you incorrectly note, practicing or writing prescriptions “under the doctor’s authority”, or requiring a physician to co-sign our orders and clinical notes.

    Nurse Anesthetists have been practicing, largely as fully autonomous providers, for around 150 years.  In that time, the doomsday predictions of an imminent “threat to public safety” that you and other physicians continue to forecast despite the growing evidence to the contrary, have never been actualized.

    As health care providers, our clinical work is now largely informed by evidence-based practice guidelines. 
    If your arguments are earnestly rooted in an honest concern for the safety of human lives, and if you value higher level studies as evidence, it is puzzling to me how seemingly easy it is for you and for others who may share your opinion, to continue to ignore the mounting evidence that consistently refutes your opinions.  The rationale that remains then, after evaluation and evidence is removed, seems to be a vigorous defense of purely your own self interests, transparently veiled as altruism. 

    Given the challenges facing the health of our nation and the world today, would not the energy and the resources currently directed toward defending your turf and self-interests be more productively and beneficially applied in a collaborative multi-disciplinary partnership actually focused on…the patients?

    Bill Wagner, DNP

  • Anonymous

    Gee Ridics, 

    I’m restricted…Did I offend you?

    • Anonymous

      Not sure what you are refering to…?  I dont have the ability to restrict anyone

  • Anonymous

    Maybe couldn’t handle the heat so you went whining to management?

    • Anonymous

      Hahah…I am clearly not who you think I am

  • Anonymous

    Well hospitals use to be able to denie mandated ER care but after a couple high profile cases…guess what there was a public outcry and a law was passed stating you cant refuse to care for a pt when presenting to the ER.

    In regards to your link…I am still attempting to figure out what I am weeping about.  I dont have time to pick apart that article and explain why it wont work well on so many different levels. 

  • stanley kristiansen

    MD’s by licensure have an unlimited liscence to practice medicine, if an institution will credential them they can do it, responsiable md’s practice in the area they are trained just as CRNA’s do.  This cannot happen with CRNA’s who have a deliniated scope of practice, with MD’s it can and does and it is all LEGAL.

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