ASA: Doctors and nurses are simply not one and the same

ASA: Doctors and nurses are simply not one and the sameA guest column by the American Society of Anesthesiologists, exclusive to KevinMD.com.

Recently, discussion about health care has reached a fever pitch, between changes in policy, adjustments to scope of practice and a multitude of other medical issues. As health care providers, it is our duty to provide the highest level of medical care to all patients to safeguard their health. We are the catalysts for change and we need to recognize practices and beliefs that are potentially harmful to those we’ve vowed to protect.

Some argue nurses and physicians are equally qualified and should be allowed to practice within the same capacity. That is unequivocally false. Rather than draw battle lines between the two disciplines, we should harness the differences and find a way to work cooperatively in the best interest of patients. The physician-led care team approach to medicine is the most logical and safe choice.

Arguments about the appropriateness and benefits of the physician-led care model occur daily in the specialty of anesthesiology. Nurse anesthetists would like to practice anesthesia care without the guidance and supervision of a physician anesthesiologist, citing comparable education and training to that of medical or osteopathic doctors.

This is a dangerous misconception. They simply are not the same.

There is no substitute for the rigorous and thorough education of medical school. After four years of undergraduate training, physician anesthesiologists complete four years of medical school and four years of post-doctoral internship and residency. Many nurses only have two to three years of post-graduate training. Physician anesthesiologists have 10,000 to 14,000 hours of clinical training, compared to the 1,000 to 2,500 hours completed by nurse anesthetists.

The education and training of nurse anesthetists and physician anesthesiologists are not comparable.. Physician anesthesiologists evaluate and supervise the medical care of patients before, during and after surgery. While nurses provide routine support, physicians’ advanced training can make the difference between life and death when critical medical decisions need to be made and seconds count to ensure optimal patient outcomes.

The fact remains: There are substantive differences between physician and non-physician members of an Anesthesia Care Team. These differences have a direct impact on the safety of the patient.

I’ve heard countless stories from my physician anesthesiologist colleagues illustrating the moments where advanced training made a critical difference. Many diagnose underlying and seemingly unrelated health conditions during pre-surgical screenings that, left undetected, would have proved fatal to the patient during their scheduled procedure. Likewise, routine procedures can become decidedly complex, and emergency intervention beyond the scope of non-physician experience and training is imperative to save the life of the patient.

Non-physician health care professionals play an important role on the care team. When their skills are combined with appropriate physician supervision, patients can receive the safest, highest-quality care available. After all, we can’t forget why we’ve dedicated our lives to health care: to keep our patients as safe as possible. Providing care below the gold standard is irresponsible and, frankly, unacceptable.

Kenneth Elmassian is on the American Society of Anesthesiologists’ Committee on Communications and is a member of the ASA board of directors. 

Comments are moderated before they are published. Please read the comment policy.

  • http://twitter.com/ReillyRN510 Kevin Reilly

    Dr. Elmassian, if patient health outcomes are better when anesthesiologists provide care compared to nurse anesthetists, then publish the data. Anecdotes are fine, but data trends and empirical evidence are what should drive policy.

    • skl

      I don’t see how you can ethically create such a study.

      • ab9302

        Outcomes studies have been done and show no difference in outcomes.

        CRNA’S have been practicing independently for decades….damning data would not be hard to find, if it existed.

        • Mengles

          Apparently you haven’t learned about the drawbacks of retrospective studies (they teach that in medical school). If you guys had actual guts, and wanted to show the difference then you would do a multicenter, double-blind, randomized, clinical trial. But then patients would get hurt – which is the reason why your lobby doesn’t fund this type of research. It’s just easier to do a dinky chart review -which is all what a retrospective study is.

          • ab9302

            I am aware of the differences between retrospective and prospective studies.

            Your suggestion that only those who’ve attended medical school are able to grasp such concepts would be found quite laughable by the many non-clinicans who are experts in biomedical research and statistics. You know, the ones that you rely on to design your studies and run your stats analyses for you.

            Surely in medical school you also learned that it is the intervention or claim that must prove itself, and not the other way around. When a new drug enters on the market, that drug must prove it’s own worth against those it competes against; we do not simply take the new drug’s manufacturer at its word that the new drug is better, and abandon the old drugs.

            Similarly, if the ASA is going to continue to assert that only they are capable of providing safe anesthesia, then it is incumbent upon THEM to produce the research supporting such a claim.

            I am sure you also learned in medical school about pilot studies, and that retrospective reviews are often used to indicate whether a prospective trial is worth setting up and funding…..see where I am going with this?

            I strongly suspect that the ASA would have scraped up the money to fund such a trial already, if the gobs of retrospective data that is already available gave any inkling whatsoever that CRNAs could actually be proven less competent.

            Put your money where your mouth is, A$A.

          • Thomas J. Mason

            “Surely in medical school you also learned that it is the intervention or claim that must prove itself, and not the other way around.”

            Yes, so if nurses want to claim that they are just as good as real doctors, they must prove that claim, not the other way around.

            If they can’t, we stick with the status quo: doctors are doctors and nurses are nurses.

          • ab9302

            Wrong. The status quo is that CRNAs are able to work independently of MDAs in every state but one.

            It has been that way for a century.

            It is the A$A is that keeps trying to change that.

            And before you bring up the new “opt outs”, remember that is nothing more than a CMS billing requirement. It has nothing to do with scope of practice. Even in non-opt out states, CRNAs can practice independently.

          • FFP

            When you say “independently” you mean without the supervision of an anesthesiologist, right? Because those nurses are still supervised by doctors from other specialties (who are as greedy as hospital administrators in playing games with their patients’ health).

            And “it’s been that way for a century”? You know what? You are absolutely right. Initially, in the United States, anesthesia was administered by nurses, under the supervision of the operating surgeons. But the “outcomes” were so “great” that the nurses were replaced soon by specialized medical doctors. And “it has been that way” for more than 50 years.

          • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

            Sounds to me like you went into the wrong field and now you’re mad because someone with less education took your job! Get over it – CRNAs are here to stay.

            BTW – why do I keep reading posts by the same physicians over and over again? Is it because the REAL physicians are too busy saving lives? Is it because the REAL physicians don’t view NPs/CRNAs as a threat?

            Why do you guys feel you need to keep validating yourself and your profession?

          • FFP

            Your ad hominem says more about the kind of person you are, than about me.

          • Guest

            How are you going to feel when pharmacists, offering to do the job even cheaper than you, start saying they’re just as qualified as you and start lobbying to do your jobs for even less money? That will be fun. I’m glad I have the money to buy myself a real doctor should I need one. Pity about the poor folks though, they’ll have to take whatever the gubmint says they’ll pay for.

          • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

            As long as patient outcomes are the same, I won’t care. You guys just don’t get it, there AREN’T enough primary care physicians. It’s too late – this ship has sailed. NPs are here to stay and there’s nothing you can say or do to change that fact.

            In my home state of NM, pharmacists and psychologists have been writing prescriptions for quite a while now and there hasn’t been a problem.

          • Guest

            NM is the 3rd poorest state in the country with a vast under served area that has no money. Much of the land is reservation and the natives live there in deplorable conditions (I grew up in NM, I know of what I speak). Who in God’s name would want to work or live there? I didn’t, and I grew up there (how I miss the green chile though)!

            Of course other practioners will need to fill the void there, and they can do so “without a problem.” Is a native woman living in a shanty without running water or electricity going to complain about the quality of care when she’s just happy someone is willing to come to her “home?” Who is following the outcomes on these people? Who honestly cares about these people? Not corporate bean counters or policy makers, I assure you.

          • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

            Is Oregon poor? What about Washington? We’ve had full independence for YEARS in those states.

          • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

            I’m sure people like you only want to work in the best conditions with the least complicated patients.

            Texas has more uninsured people than anywhere else in the country, but NPs aren’t allowed to work independently.

          • eric sanders

            Cyndee there have been two recent articles showing that patients are more likely to die in critical access hospitals wether it is a medical admission for certain diagnosis or certain surgeries. The kicker is that we all know who staffs these critical access hospitals….you guessed it mid level providers(PA, NP, Anesthesia nurses, etc)

          • Noni

            Eric, can you please provide links to these articles? I’d love to read them, thanks.

          • eric sanders

            Noni, both articles I believe were in JAMA in April.

            “For the JAMA study, Joynt and colleagues examined risk-adjusted, 30-day mortality rates for Medicare patients suffer a heart attack, heat failure, or pneumonia from 2002 to 2010 at CAHs and non-CAHs.

            They found that mortality rates at CAHs rose an average of 0.1% per year over the nine-year study period. In comparison, mortality rates at non-CAHs dropped an average of 0.2% per year.

            By 2010, the overall mortality rate for the three conditions at CAHs was 13.3%, compared with 11.4% at other acute-care hospitals.”

            The article regarding surgery stated that there was no increased rate of mortality for surgeries in CAH for appendectomy, cholecystectomy and hip replacements. But for pts who had surgery for hip fractures CAH had an increased risk of mortality. So essentially critical access hospitals can handle simple procedures but mortality increases with complex pts with multiple medical problems such as the elderly who fall and fracture a hip .

          • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

            I thought you said that CAH’s were staffed with only PAs or NPs? So, now you’re claiming they’re performing surgeries too? That is such nonsense.

          • eric sanders

            Cyndee, I never said that CAH were staffed “only” with midlevels. CAH are staffed with many midlevels at often very high ratios compared to non-CAHs. Laws are also in place the discourage hospitals from employing physicians such as anesthesiologist. Look up rural pass through law…it essentially encourages hospitals to hire anesthesia nurses instead of physician anesthesiologist because if they hire the former they will bill medicare at higher rates. Trust me I am not arguing against midlevel providers…they are a very important aspect of healthcare. I am arguing against their complete independence without any physician oversight. For example, CMS just recently stated that if a state nursing board defines a CRNA scope of practice to include pain management which would include everything from cervical epidural steroid injections to spinal cord stimulators then CMS will pay the CRNA the same as a physician anesthesiologist. The problem with this is that CRNA have zero required training in pain medicine…how is this a sound thought process.

          • Noni

            Interesting, thanks. i’ll search for the actual articles as I’d be curious to see which hospitals were included in the study. There was another blog on this site that described how the CAH distinction was abused by hospitals (either for financial gain or to avoid certain regulations, I can’t remember the exact reason) though largely it does refer to rural hospitals and those in blighted areas.

          • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

            I don’t know any nurse practitioners who practice in a hospital setting. I suppose the big hospitals in the big cities may have an Acute Care NP working in COLLABORATION with an internist, but definitely NEVER on their own.

            I LOVE doing what I do – I provide high quality health care at a very low price. It seems that you guys are getting all bent out of shape because we’re getting the uncomplicated cases. You should be THRILLED that your schedule isn’t filled with the types of cases I treat at my clinic.

            It just blows me away that I know so many physicians who are BEYOND supportive of me and my practice, yet I get on this site and read all these inflammatory comments posted by NP haters. Just blows me away.

          • LastoftheZucchiniFlowers

            who else sees patients besides you? How many patients do you see in an average day? Who co-signs your charts (or a portion of them)? Your price list is most interesting and you seem to employ several people – but I am very curious about your neighbor, “Weapons at Hand” Would you care to elaborate?

          • LastoftheZucchiniFlowers

            Ms. Malowitz: Is Dr. Gray your SUPERVISING physician? Could you own your clinic and see patients without him?

          • FFP

            Cyndee,

            You seem not to realize that having a CRNA (instead of an anesthesiologist) responding to very acute and potentially life-threatening situations intraop is not the same as treating chronic pain, or other family medicine issues. While for the latter one can consult a book or another professional and even call back the patient later, in an (super)acute situation one has only one’s own knowledge and skills, and only tens of seconds to decide AND act.

            Many CRNAs not only don’t have the knowledge to deal with sicker patients (i.e. most of the elderly), but they don’t even know how little they know. On the other hand, they are very good at asking to work independently so that they can be reimbursed at the same level as a physician, while cherry-picking the easy cases, and leaving the stressful, work-intensive, complicated cases to the doctors.

            As an anesthesiologist, I am honestly fed up with having to pick up their crap, and fixing or preventing their mistakes. It’s like letting your kids drive while being responsible for every stupid thing they do. Except that these people are not your kids…

          • Guest

            Very interesting. I have never worked with CRNAs (there were a few at my medical school and very few at my residency) but I’ve only worked in MD staffed groups (I am anesthesiologist too).

            One local hospital used to have CRNAs run the OB floor until a patient and baby died as a result of amniotic fluid embolus. I thought that could happen to anyone, but the hospital immediately put a supervising MDA on OB.

          • FFP

            That could happen to anyone, even if you do all the right things.

            Your story makes me think that there must have been some substandard anesthetic care involved. One cannot blame the anesthesia provider for her patient dying of amniotic embolism.

          • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

            If an anesthesiologist had been in charge, the outcome would have been the same. What would the hospital have done then?

          • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

            I can assure you, they’ll never be reimbursed the same. I own my clinic and insurance companies reimburse me horribly – FAR less than a physician for the same uncomplicated visit. Insurance companies delight in taking advantage of us. I’m in the process of renegotiating my contracts. If it doesn’t work out, then I’ll tell them what they can do with their contracts. I see enough of the uninsured to sustain my practice. The rest…I can bill out of network and get reimbursed substantially more.

          • ninguem

            Well, here’s the question. Why DO you “pick up their crap, fix and prevent their mistakes”?

          • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

            I can’t believe you would ask that question. I hope you’re not a physician.

          • Guest

            Approximately 65% of CRNAs practice under the supervision of real anesthesiologists. Y’all are still just nurses.

            If you had wanted to be a doctor, you should have gone to med school.

          • http://www.facebook.com/preston.gorman.9 Preston Gorman

            Is this an example of “I know you are but what am I?!” Pee Wee would be proud…

          • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

            Kinda like those retrospective chart reviews my collaborating physician does on 10% of my patients?

          • Mengles

            Yes, bc outpatient primary care visits for a cough or cold is the same as being put under general anesthesia for surgery.

  • http://twitter.com/priscillanovak Priscilla Novak

    I would like to see what research has been done on this topic and if there is any published findings where there is an actual difference in patient outcomes.

    • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

      Priscilla – all the studies show the outcomes are the same. That’s why no one answered your question. I don’t understand why you got 2 “thumbs down” on your post. I guess they have a problem when someone brings up a valid point.

      Seriously, there’s no sense in arguing with the people on this site. G-d forbid you state something completely relevant, because then it gets deleted. It’s like they don’t want the general public to know the truth.

      • Guest

        Then Cyndee, I guess you’ll have no issue with your elderly frail parent or grandparent having cardiac surgery under the care of a solo nurse anesthetist, correct? The outcomes are the same!

        • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

          My daughter had surgery 2 weeks ago under the care of a solo nurse anesthetist. If there was an anesthesiologist around, he/she never made an apperance.

          CRNAs have been around for years – there have been NUMEROUS studies to prove the outcomes are the same. If someone is going to undergo a heart/lung transplant, then that will be done in a large hospital with an anesthesiologist giving the anesthesia.

          • Guest

            Why? if there are “numerous studies” showing the outcomes are the same then why would an anesthesiologist be required for complex cases?

          • LastoftheZucchiniFlowers

            Cyndee – are you being deliberately naive? Of course he/she was around and you didn’t see him/her because it wasn’t necessary for your daughter’s care. Your comments seem quarrelsome which is odd for someone who wants to advocate the role of midlevels. I say this as a proponent of midlevels in the collaborative role. The adversarial role of this thread (and others) is unbecoming at best and destructive at its worst for midlevel and physician providers BOTH.

    • MM

      See Eric Sanders’ comment up towards the top. Quoting:
      ——————————————-
      The study in Health Affairs that nurses keep citing is an incredibly
      poor measure to change policy that will effect millions of patients.
      The study looked at medicare billing data over a 7 yr period. The study
      excluded patients with more than one hospitalization during a quarter
      and procedures that occured in ambulatory surgery centers. The 7 yrs
      included 741,518 surgical discharges. One third did not have an
      anesthetic claim because they were likely procedures in a lump and bump
      clinic under local that did not require an anesthetic by an
      anesthesiologist or CRNA. The author decided to exclude the vast
      majority of the cases without an anesthetic charge except for the ones
      provided in a rural pass through hospital were CRNAs practice solo (talk
      about padding stats). After the exclusion the author had 481,440
      surgical discharges. Of which 412,696 occurred in non op out states
      were CRNAs are required to be supervised by a physician. 68,744 occured
      in opt out states were CRNA did not have to be supervised by a
      physician. Of the 68,744…41,868 occurred before opt out was passed
      into law. Thus, only 26,876 of the 481,440 surgical discharges were
      performed by solo CRNAs which included the cases in which no anesthetic
      was likely even performed in rural pass through states. So to start
      this study is invalidated just by looking at numbers alone considering
      the risk of anesthetic mortality is around 1:250,000 surgical cases and
      the study only looked at 26,876 surgical cases performed by a
      non-supervised CRNA. But even more surprising is that the study showed
      that anesthesiologist working solo took care of patients who were
      considerably more complex with expected increase in motality of 7% based
      on this finding. But the data showed mortalities to be similar between
      CRNAs and anesthesiologist. So in summary CRNAs who work solo provide
      very few anesthetics in opt out states compared to the team model or
      solo anesthesiologist practices and even though they perform anesthetics
      for simpler procedure they have a similar mortality rate to
      anesthesiologist doing cardiac, neuro, transplant, vascular, etc. Hmmm
      who do I want providing my anesthetic….a physician or an anesthesia
      nurse.

  • FFP

    Stop asking for studies. You know very well that no hospital administrator in her right mind would allow nurse anesthetists to perform unsupervised anesthesia in high risk surgeries or patients, not without the safety net of a MD.

    Of course, there is no big difference in outcomes when a nurse anesthetist is SUPERVISED by a physician. There is no big difference in outcomes even with supervised RESIDENTS (who follow instructions much better than their arrogant CRNA counterparts), but that does not mean that residents should perform unsupervised anesthesia, does it?

    And of course there is no difference in outcomes for easy procedures or patients. One could train a monkey to do some of those cases; there is no medical judgment, just routine and manual skill.

    In healthcare, the most dangerous type of people are those who don’t know how little they know. Usually, they are found among the most vocal ones…

    • Guest

      I thought in some states CRNAs were allowed to practice without physician supervision (CA, for example). In fact, my mother had facial plastic surgery in an office setting and her anesthesia provider was a CRNA. Later came to find out this surgeon used CRNAs as a cost saving measure because the same individual could provide anesthesia and serve as the PACU nurse.

      That same plastic surgeon now uses anesthesiologists only. He complained about incident after incident of issues with extubation and fear for patient safety.

      I digress though. Couldn’t states like CA offer data regarding patient safety and outcomes when care if provided by an anesthesiologist versus a CRNA? Just make sure a nursing organization doesn’t offer to sponsor the research…

      • ab9302

        They do.

        There are many places where CRNA’s are the only anesthesia providers.

        Even in settings where CRNA’s are “supervised” or “directed”, they very often work almost entirely autonomously.

        “Supervision” and “direction” are billing arrangements that allow anesthesiologists the ability to bill for the work that CRNA’s or residents “under them” perform.

        They have very little to do with actually “supervising”.

        • FFP

          You are absolutely right. If anesthesiologists were adequately supervising, a lot of CRNAs should be either fired or lose their license for going beyond the level of “autonomy” the law allows in most states. The only reason we don’t see more problems stemming from this is that the anesthesiologists put out the fires before they burn down the house. Not only that, but when the same anesthesiologists complain about CRNAs overstepping their legal boundaries to the level of reckless behavior, the hospital administrators tend to look the other way, because nurses tend to behave like a union, while doctors fight (or not) individually. ;-)

      • LastoftheZucchiniFlowers

        Guest – ‘facial/plastic’ surgeons in Cali are not known for cost-containment measures given the up-front $$$$ nature of their practices. Odd that the CRNA would agree to diminish his/her role AND that said surgeon now must pay for the doc and a pacu nurse? How did this behoove him and his bottom line? Just curious.

    • Mengles

      That’s one thing these hypocrites would never do which is allow their own sick parent or grandparent to be only under a nurse anesthetist. 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. But guess who Clinton had when HE needed surgery – an anesthesiology physician.

    • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

      That’s where the additional education comes in – anesthesiologists take care of the sicker patients. The uncomplicated ones go to the CRNAs. Why would you have a problem with that?

      CRNAs have practiced independently for YEARS in several states, including my home state of NM. They have the same outcomes as an anesthesiologist – get over it. It’s a DONE DEAL. You guys sold out your profession years ago – shouldn’t have gotten so GREEDY.

      • Guest

        Is this similar to you demanding your supervising physician to pay you per patient rather than the salary you were receiving? Pot or kettle?

        • Guest

          What are you talking about? I’ve owned a clinic for several years – it’s mine 100%.

          My collaborating physician doesn’t pay me…the patients/insurance companies pay me for my services. Do you have me confused with someone else?

          • Guest

            No, I am not confusing you with anyone else, and I see you’ve learned your lesson by posting anonymously now. Well done.

          • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

            I’m not posting anonymously – any time I’ve tried to edit a comment, it posts as “Guest.”

            What difference does it make anyway b/c my comments keep getting deleted. So much for free speech on this site!

          • LastoftheZucchiniFlowers

            Cyndee – who pays Dr. Gray?

          • Cyndee Malowitz

            he’s her husband

      • Mengles

        That’s bc the CRNA lobbying group is not just demanding seeing the uncomplicated ones. They want all the cases, with no supervision at all. That’s why CRNAs won’t dare do randomized controlled trials with complicated patients, just the “easy” ones, so they can proclaim to be just as good as anesthesiologists.

        • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

          They don’t want the complicated cases – that’s ridiculous.

          • eric sanders

            Clearly shows that you have no idea what you are talking about. They are constantly claiming equivalence. They will also claim they are trained to be fully independent once they graduate which included all cases. I can promise you they are not but that is not what they tell the hospital CEOs and legislators

          • Guest

            As an anesthesiologist, I wonder, what will happen if my entire group is replaced by CRNAs and the surgeons complain about quality? Will anyone care? Will it matter? Will those with money simply seek out the hospitals that retain MD anesthesiologists while the poor and disenfranchised accept CRNAs?

            I currently work with the latter group of patients and I honestly wonder if they’d care at all about who showed up to provide anesthesia. 99% would not as they are happy to receive any care at all. The other 1% would simply seek care elsewhere.

          • LastoftheZucchiniFlowers

            Would be a good time to remember that midlevels got started in Colorado when a physician postulated that a higher level of RN could provide pediatric care to children with uncomplicated presentations given additional training. That was in the sixties. From that program all midlevel programs grew (both PA and NP). So yes, medicine DID create these new groups of providers. Just as ‘medics’ and independent duty corpsmen in the military work as surgeons in combat (quite effectively) – they nonetheless have no analagous licensure in the civilian sector once they’re out of uniform. While the world is changing, change is never easy, especially when turf/cash/perks and power have to be doled out to a different set of players. Nonetheless, in the end – the doc holds the ball and if it gets dropped (by someone else) – the doc takes the fall. Ask any plaintiff’s attorney and read some of the sobering risk management literature.

      • MM

        That’s where the additional education comes in – anesthesiologists take care of the sicker patients. The uncomplicated ones go to the CRNAs.

        ——————————-
        What do you do if one of your “uncomplicated patients” suddenly suffers life-threatening complications? If things rapidly escalate out of your skill zone?

        Do all nurses even know enough to know what they don’t know?

        • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

          So, you’re saying that CRNAs don’t know what to do if a patient suddenly develops life-threatening complications? Seriously? You don’t think they’ve been trained in those situations? Of COURSE they have! They encounter those situations every single day. Have you even read all the studies comparing the outcomes between CRNAs/anesthesiologists? The outcomes are the SAME.

          I’m refering to cases that start out complicated, such as heart/lung transplants. I have no doubt an anesthesiologist is going to be in charge AND PAID ACCORDINGLY for those type of cases.

          I’ve had to deal with life threatening situations at my clinic and it’s a minor emergency clinic! I have to act quickly while we waiting on an ambulance.

          • Guest

            Cyndee, with all due respect, your ignorance on this topic is obvious. You don’t know how a CRNA is trained vs an MDA, you don’t know what CRNAs are lobbying for in terms of equality and yet you claim the outcomes between the 2 groups are equivalent despite not citing a single study (and honestly I don’t think a poster in here believes you have read a single study about CRNAs).

            Unless you have personally worked with MDAs and CRNAs in an OR you have no basis for your claims that CRNAs know how to handle complications or life threatening emergencies.

            I have no doubt you are capable and competent. But people pointing out you are not equivalent to a physician should not make you so defensive, and yet it does.

  • Suzi Q 38

    No one said they were the same.

    • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

      Thank GOD they aren’t the same!

  • ab9302

    The A$A keeps responding to arguments that no one is making.

    Here is a partial list of those entities who have endorsed, either explicitly or implicitly, independent CRNA practice:

    - US Congress (via the Affordable Care ACt)
    - CMS
    - The 17 state’s who’ve “opted out”
    - The IOM
    - The Rand corporation
    - The American Hospital Association
    - Numerous state hospital associations
    - The US Navy
    - The US Army
    - The US Air Force
    - Perhaps most tellingly, the malpractice insurance industry

    I guess they all just haven’t seen all the research that shows how unsafe CRNA’s are? Oh, wait…..

    • Mengles

      Newsflash: All those organizations support your cause, especially the American Hospital Association, bc CRNAs are cheaper labor. It has nothing to do with actual safety for patients.

      • ab9302

        Is unsafe labor cheaper?

        Does the military have better or poorer outcomes than the civilian world?

        Why do malpractice companies keep lowering our premiums?

        • Mengles

          1) Cheaper has to do with the fact of your level of skills and training.

          2) If you get your care through the military (the government) you can’t SUE the government for a poor outcome and win.

          3) Sure they do. It’s nice to have very low liability compared to the anesthesiologist.

          • ab9302

            I think you misunderstand how liability insurance works…..

            Underwriters charge premiums based on risk, which is calculated based on constantly-reviewed data on litigation.

            Unsafe providers get sued.

            Providers who get sued don’t have their premiums lowered; they have them raised.

            CRNAs who work independently have seen their premiums go down steadily for decades.

            If CRNA’s were not capable of safely providing anesthesia care, they would hurt people and they would get sued and their premiums would go up, instead of down.

            I think you also misunderstand military trauma care.

            Read up on the survival rates of those traumatized serviceman who require forward emergency surgery. They are impressively better than those found in the US. While you are at it, educate yourself on who provides the anesthesia for the vast majority of those surgeries…..

          • Guest

            You offer no proof that your malpractice insurance rates are dropping, you just claim they are. Do you have data to support this?
            Guess what? Over the years malpractice rates for anesthesiologists has dropped too. This is because the practice of anesthesia has become safer thanks to monitors ike pulse ox and ETCO2. This should not be used as your evidence for how safe CRNA care is.
            I have colleagues who are CRNAs and I’ve been fortunate to work with some great ones as well. I think they are capable for the most part. That said, I know the difference in training and the difference in thinking. I plan to be part of the elite group of patients who will pay more for doctors, including anesthesia providers, when midlevel care becomes the standard for the masses thanks to the ACA.

          • Mengles

            Karen Sibert was right – Anesthesiologists have made anesthesia so safe – it’s almost like they are a victim of their own success.

          • Guest

            Pretty much, which is ok. Much of anesthesia is boring IMHO. It forces us to find a niche or subspecialty that keeps us stimulated.

            My neighbor is a CRNA and one of the kindest, most hard working people I’ve met. I have no issue with CRNAs. My issue is the desire for the full equality and autonomy currently afforded to anesthesiologists. I don’t think that’s appropriate, and the intelligent CRNAs that I know aren’t seeking that. They are happy to have a job which I fully respect.

          • eric sanders

            I actually just talked to the biggest provider of malpractice insurance to anesthesiologist in the country and asked if they covered CRNAs and the answer was “no”. When asked why, the lawyer stated that the company felt like there was to much risked involved with independent CRNA practice.

          • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

            Eric Sanders – tell us the name of the biggest provider of malpractice insurance and I’ll verify what they supposedly told you.

            So, do they have lawyers speaking to potential clients nowadays?

          • eric sanders

            A Cyndee it was at a conference months ago and the person representing the company stated he was an attorney…so I guess I believed him. I did not ask to see proof of his credentials and I do not need you to verify what he said…thanks for the offer.

          • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

            Exactly what I thought. You can’t even remember the name of the biggest insurance provider for anesthesia services.

          • eric sanders

            I do. Just no reason for me to tell you.

          • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

            No reason to tell me, because you’re LYING.

          • Mengles

            Why, so you can malign and badger that insurance company as well?

          • Guest

            Because I think you’re lying.

          • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

            Yes Dr. Mengele, because I have so much time to do that.

          • Mengles

            Which goes to show you that even the actuaries don’t trust those studies, no matter how much lobbying groups and hospital associations say.

          • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

            Mengles…but we can sue the physicians who defame us. If anyone slanders me, they better be able to back up their comments in court. You might want to think twice before you go around slandering NPs/CRNAs. I’ve been reading your post for awhile. You’re walking on thin ice.

          • Mengles

            Sorry, but being offended doesn’t mean you have the right to compensation for suing. But then you would know all about lawsuits.

          • _userM9801

            I feel like I’ve wandered in on the middle of a soap opera :-/

          • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

            Because you did!

          • Nils

            Comments have devolved to the level of a YouTube comment section, or teenaged girls arguing on Facebook.

          • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

            Wonder why my comment was deleted?

            Guest – do you know how creepy it is that you googled me? Yeah…looks like that pain management doctor needed to be supervised by a NURSE. BTW – some of my closest friends are physicians. A very good friend is an anesthesiologist and pain management physician as well! So, that blows your theory about my supposed hatred for anesthesiologists, doesn’t it?

          • http://www.kevinmd.com kevinmd

            Comments are automatically deleted by the system when a specific number of readers flag it as inappropriate.

            Kevin

          • Guest

            If that’s the case, then I’m surprised that any of my comments make the final cut!

          • Guest

            You yourself keep deleting your name from many of the the comments you have submitted, Cyndee. Why?

          • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

            I didn’t – I tried to edit them and when I reposted them, they were posted under “Guest,” and then I was unable to change it. I think it’s pretty obvious I’m not posting as anonymous…unlike you.

          • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

            kevinmd – If that’s the case, then I’m surprised any of my comments make the final cut!

          • LastoftheZucchiniFlowers

            finally!

          • Guest

            I don’t understand why people post here using their real name and are then SHOCKED when some anon on the internet googles them or researches them. Be more careful protecting your identity if you’re going to make inflammatory statements anywhere. You’re going to draw attention to yourself and it won’t be positive. This could affect your career as things posted on the internet tend not to go away and any patient, future boss or HR department can easily find them. Use a pseudonym. My PSA for you for the day.

          • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

            A coward, I’m not! I’m my own boss and I work for my patients. My patients LOVE ME because I advocate for them. That is EXACTLY why I want my comments public. I stand up for what’s right and I want people to know it. I will always advocate for my patients and my profession, because I believe it’s morally and ethically the right thing to do.

            I suppose I can understand why you’re posting anonymously. God knows your boss or HR wouldn’t be happy that you’re slamming the very professionals who treat the majority of their patients. I totally get that.
            I’m not shocked that you googled me…I just think it’s creepy, but I guess I should be flattered. That just proves you aren’t busy enough or you’re letting your NP or PA do all the work while you post garbage on the internet.

          • Guest

            Cyndee, first of all, there are multiple anonymous posters here.

            Second, I’m embarrassed as a female practitioner that you are posting such inflammatory and emotional posts. You do female practitioners no favors by being unprofessional and screechy.

            Third, bashing other practitioners is neither morally nor ethically correct. It’s just immature.

            I believe physicians and midlevels both have roles in medicine. However, I get annoyed when midlevels call for equality when they have no desire to prove themselves equal with education or testing. Put up or shut up, that’s what I say!

          • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

            Thank you for providing the perfect example of the pot calling the kettle black.

          • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

            I don’t know why you’re pitching such a fit – my comments keep getting deleted.

            This site is fixed so that unpopular comments get deleted – how CONVENIENT! I’ll join a site where everyone gets to have a free voice.

          • Mengles

            No one accused you of being a coward.

          • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

            That’s 2 comments that were deleted and they weren’t even inflammatory. Just because I told the truth, all you guys just had to delete it, because God forbid the public read it. This site is censored – KevinMD – I get that.

          • http://www.kevinmd.com kevinmd

            Comments get automatically deleted by the system after a specific number of inappropriate flags by the readership.

            Kevin

          • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

            Why don’t you go to the article “Why doctors should use their real names on Twitter” on KevinMD. Both Dr. Sara Stein and Dr. Woo made an excellent point. I tried to “cut and paste” their comments, but my ipad isn’t cooperating. The article was just published in April 2013 – you can find it.

            I’m wondering if any of the anonymous posters on this site are truly physicians or if they just flunked out of CRNA school. It’s all becoming much clearer now. If you’re a real physician, then you should own your comments. Quit posting anonymously.

          • Guest

            I personally post anonymously because I have nothing to own or prove by posting here. I post for entertainment and education. I have a family and small children and I don’t want some internet whackadoodle giving me or them unwanted attention. Call me paranoid, but I know there are some real cuckoos on the internet in every forum. This is a public unrestricted forum. I think posting anonymously is just common sense. For those who want to post using their real identity, go for it! I just want to be a bit more cautious.

          • Mengles

            Maybe bc you were threatening lawsuits and saying I’m on “thin ice”?

          • Guest

            Wish I could see that deleted comment! She is doing NPs no favors with her inflammatory comments.

          • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

            Oh yeah – as if anyone can possibly change your perception of NPs.

          • kjindal

            stating an opinion in a blog forum debating advance practice nurses vs physicians is not slander; you are showing your ignorance, as you have done recently on this blog. And please clarify if there was an issue with taking charts from your former employer’s office, without patient consent. That, in my opinion, should bar you from any provision of healthcare services, and from this blog. But I am not the state of texas, or Kevinmd.

          • LastoftheZucchiniFlowers

            meng – I must correct you on this. Only an active duty patient is prevented from suing Uncle Sam. Anyone else (the military member’s family, retired military personnel, etc.) who are military beneficiaries can and DO sue Uncle, and even WIN their cases. Just a point of clarification.

    • Guest

      It looks so grown up for you to keep calling it “the A$A”. Because nothing about YOUR lobbying efforts is motivated by dollar signs, IS it? /sarc

      You childish petulant chip-on-the-shoulder envy-riddled ¢rna.

  • John Henry

    The “argument” is an invidious one propagated by the government and insurance companies so that they can resist paying higher amounts–increases that have been promised, FWIW– for primary care services. If the less costly to train non-physician provider can be made to seem the “same” as a physician then paying only what they think the market will bear for that lesser-trained person is the planned outcome.

    Follow the money.

  • eric sanders

    The study in Health Affairs that nurses keep citing is an incredibly poor measure to change policy that will effect millions of patients. The study looked at medicare billing data over a 7 yr period. The study excluded patients with more than one hospitalization during a quarter and procedures that occured in ambulatory surgery centers. The 7 yrs included 741,518 surgical discharges. One third did not have an anesthetic claim because they were likely procedures in a lump and bump clinic under local that did not require an anesthetic by an anesthesiologist or CRNA. The author decided to exclude the vast majority of the cases without an anesthetic charge except for the ones provided in a rural pass through hospital were CRNAs practice solo (talk about padding stats). After the exclusion the author had 481,440 surgical discharges. Of which 412,696 occurred in non op out states were CRNAs are required to be supervised by a physician. 68,744 occured in opt out states were CRNA did not have to be supervised by a physician. Of the 68,744…41,868 occurred before opt out was passed into law. Thus, only 26,876 of the 481,440 surgical discharges were performed by solo CRNAs which included the cases in which no anesthetic was likely even performed in rural pass through states. So to start this study is invalidated just by looking at numbers alone considering the risk of anesthetic mortality is around 1:250,000 surgical cases and the study only looked at 26,876 surgical cases performed by a non-supervised CRNA. But even more surprising is that the study showed that anesthesiologist working solo took care of patients who were considerably more complex with expected increase in motality of 7% based on this finding. But the data showed mortalities to be similar between CRNAs and anesthesiologist. So in summary CRNAs who work solo provide very few anesthetics in opt out states compared to the team model or solo anesthesiologist practices and even though they perform anesthetics for simpler procedure they have a similar mortality rate to anesthesiologist doing cardiac, neuro, transplant, vascular, etc. Hmmm who do I want providing my anesthetic….a physician or an anesthesia nurse.

  • Fourth year med student

    My surgical experiences include 4-5 surgeries per day, 6 days a week for 6 weeks, amounting to perhaps 150 surgeries total I have scrubbed into. I’ve worked with both NPs and MDs helming the anesthesia post. Both seem to be very avid angry birds players! (I’m going into IM and that’s my shot at my anesthesia counterparts.)

    Here is my point, when the surgery is going smoothly and according to plan (I did my surgery rotation in an upscale, suburban, community hospital) you could train a chimp to do the anesthesiologist’s job. Program a machine to look for medication interactions/contraindications and have a monkey push the drugs.

    The true purpose of having a highly trained medical professional monitoring the patient during surgery is to keep the patient alive when the proverbial feces hits the fan. An objective indicator for anesthesia-related efficacy would be comparing the data of health outcomes following severe medical complications during surgery, MD vs APN.

    • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

      Yeah, because physicians do such a good job keeping people alive…Dr. Conrad Murray.

      • Guest

        An unethical cardiologist FYI. Lets talk about those NPs up in Oregon who inappropriately prescribed narcotics, shall we? There are bad apples on both sides of the fence.

        • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

          I would rather talk about all those pill mills in Florida – we get to blame those on physicians 100%, considering NPs aren’t even allowed to prescribe controlled substances in that state. Better yet, why don’t you scroll down and read about the pain management doctor in CC who is getting ready to lose his license. I only wish I could provide the copy of the medical board’s amended complaint – it would blow you away. ; )

          • Fourth year med student

            I am not sure why we are trying to argue based on anecdotal evidence. What we need is a new study to be conducted so that generalizable information could be gleaned and conclusions could be made about the impact of advanced education on health outcomes.

    • Guest

      While I generally loathe hearing the “wisdom” of medical students I feel this post is right on.

    • EmilyAnon

      “you could train a chimp to do the anesthesiologist’s job….”

      That reminds me of an old Twilight Zone TV episode where a plastic surgery patient is about to have her face bandages removed in her hospital room. As the bandages are slowly pulled away, a beautiful face of a young woman is revealed. There are gasps of horror in the background with cries of “we failed”, “she’ll never be able to go out in public”…..The camera pulls back to reveal the operating team are a bunch of hairy apes.

      • Noni

        I love that episode. Miss that show!

    • FFP

      That reminds me that you could train a chimp to hold the retractors for the surgeon, which is exactly what 95% of your “surgical experiences” amount to.

      If you are scrubbed in, you have ZERO idea what the anesthesiologist is actually doing on the other side of the drape, the so-called “intelligent” one. ;-)

      I know that mommy and daddy are proud that you are in medical school, but this is adult talk, and professionally you are in kindergarten.

      • Fourth year med student

        I apologize if I offended your sensitivities. I should have written my post with more tact.

        My mother and father are quite proud, as am I. It has been a long, challenging and incredibly demanding road to get to where I am today.

        The question is, does the grueling education and training make a difference. I argued that in run-of-the-mill, outpatiet, well-controlled surgical operations it is not difficult to follow a standard protocol and produce great results. However, in the rare circumstance that something goes terribly wrong, do the extra thousands of hours learning about physiology, pharmacology, anatomy, microbiology make a difference? We should conduct a study looking at health outcomes in those settings specifically.

        The goal of my post was to elaborate on Dr. Elmassian’s point at the end of paragraph 6. I suppose that was lost by the “chimp” bit.

        • Guest

          I think the problem is that conducting a study with ASA4s having cardiac, vascular or thoracic surgery with an MDA vs an unsupervised CRNA would be completely unethical and no hospital administrator would ever agree to participate in such a study. Would you want to volunteer your 88 year old grandfather to have his CABG with an unsupervised CRNA?

          I’m sure the outcomes in ASA1s having boob jobs is equivalent between CRNAs and MDAs. But that’s not what matters, is it?

          So the studies that come out are retrospective and selective for certain types of patients. They are flawed and always will be.

        • ninguem

          “you could train a chimp to do an anesthesiologist’s job….”

          …..shit, he’s on to me……..

      • Guest

        I remember as an intern being scrubbed in on esophagectomies (I was typically at the patient’s feet trying to get a peek). Until I became an anesthesiologist I had NO clue how hard he or she was working on the other side of the drape. Never heard a peep out of them despite the fact we had lung isolation on sick, cancer riddled elderly patients.

    • Mengles

      Surgeons could very well say that you can train a chimp to write daily progress notes, write orders, and round all day without actually accomplishing anything (as you’re going into IM).

      • Fourth year med student

        Your arrival at the conclusion that I was insulting surgeons is unfathomable.
        The anesthesiologists are rightfully insulted by my characterization of
        their work and I did apologize. Where did I slight the work of
        surgeons?

  • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

    There is far more dirty laundry on your side. The pill mills are located in states where either NPs can’t prescribe controlled substances (Florida) or they’re supervised and working under a drug lord. Sure there are isolated cases from both sides, but the major stuff involves physicians.

    • Guest

      What if you were to compare apples and apples: how many doctors offend, versus how many nurses who are allowed to practice independently and who are allowed to prescribe opioids without supervision offend?

      There’s no point in rejoicing that nurses who aren’t even allowed to independently write scripts for oioids aren’t abusing their right to independently write scripts for opioids.

      • smallfarm1

        Thats an excellent question! Can you supply any data at all?

  • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

    What about Washington, D.C. – we have full independence there too.

  • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

    MM – there you go misleading people. I opened the first link…Mortality rates worsen at small, rural hospitals due to an AGING POPULATION AND BUDGET CUTS.

    I didn’t even bother clicking on the second link. Nice try.

    • eric sanders

      So budget cuts and an increasing elderly population are being seen more by CAH than other hospitals?

  • Coachpatrickv

    Root cause = ineffective communication behaviors

  • buzzkillerjsmith

    Is Oregon poor? Ever been to Roseburg? If not, please don’t go, and keep your eyes on the road if you go by on 5. Practiced there for a couple years. I don’t want to talk about it.

Most Popular