Sigh. In another indictment on the worth of anesthesiologists in the operating room, a study in Health Affairs has declared that patients who receive anesthesia from CRNAs are no more likely to suffer a complication than those who are anesthetized by anesthesiologists. The authors of the report looked at anesthetic complications in states who opted out of Medicare's rule requiring physician oversight of CRNAs vs. states who did not opt out. They found no differences in the reported rates of deaths or complications from anesthesia. They also looked at the complication rates before and after states opted out. Again there were no differences. They only found that anesthesiologists tended to perform more complicated anesthetics, perhaps due to CRNAs doing more work in small rural hospital settings.
For any anesthesiologist who has worked with CRNAs, the results should come as no surprise. Though we hate to admit it, most of them are every bit as competent as MDAs. I wonder though how much of this equivalency is the result of the evolving nature of anesthesia. Are anesthesiologists and the ASA, in our relentless pursuit of patient safety, devaluing our own work? It was not that long ago that the practice of anesthesia was a tedious, tiresome, hands-on drudgery. Back before automated sphygmomanometers, the anesthesiologist had to crouch under the drapes to measure the blood pressure by listening for distant Korotkoff sounds in a noisy operating room. Good luck if the patient was hypotensive or the arms were not accessible. In the days before capnography, anesthesiologists were literally tethered to the patient by a precordial or esophageal stethoscope to ensure the airway was patent. Nowadays with all the automated monitoring in the operating room, an anesthesiologist is free to walk around the OR to chat up the surgeons and the nurses or just to stretch his legs.
Anesthesia is so safe now that anesthesia attendings feel comfortable leaving a CA 1 resident in the OR by himself to do a case while he goes to another room nearby to teach a different resident. The safety profile of anesthesia is so high that it takes thousands of cases to find any meaningful rates of complications. Take for instance the recent quick demise of rapacuronium. The FDA tested this new muscle relaxant on thousands of patients before approving its use. It was not until millions of doses had been given that the FDA realized there were serious side effects of the drug and had it quickly pulled from the market. Succinylcholine would not stand a chance of approval today.
Is it any wonder that, despite the ASA's demagoguery of CRNAs, their work holds up just as well as anesthesiologists. I fear it will get more difficult in the future for anesthesiologists to justify our reimbursement levels when we can't prove that our skills are any more valuable than CRNAs', not when technology has leveled the playing field for everybody.
Anesthesiology value lies in critical care/intensivist role, clinical anesthesia does not routinely require the level of education mandated by ASA/ABA.ReplyDelete
I wonder if it's even that much. Pulmonologists are very active in the critical care field and any surgeon will tell you that surgeons make the best post operative intensivists. Really the only function unique to anesthesiologists is Regional or Pain. If not for legislative obstacles the CRNAs are trying to infiltrate those fields too.ReplyDelete
Before TEFRA, CRNA & Anesthesiologist relations were more consultative, collegial & respectful, since TEFRA they are more adversarial & suspicious. Hospitals & Payers use this conflict to their advantage when negotiating with either party.ReplyDelete
Using Game theory analogy, ASA and AANA too often choose a "Zero sum" approach meaning for one side to win the other side must lose. If an "N-person" approach were chosen, aligning ASA & AANA mutual interest, like the recent FDA propofol warning label, results are mutually beneficial.
I simply cannot agree. CRNAs do not equate to MD Anesthesiologists. Sure, everyone is entitled to an opinion,...but from what I've seen in a major metropolitan area at one of the best teaching hospitals in the country... the average CRNA does NOT equate to MD. There are outliers... and that goes for CRNAs and MDs. It's like you're comparing dentists to dental hygenists. It's not the same.ReplyDelete
As a CRNA with 25 years experience, to include 9 years in the Army and 10 years in a level one institution, I will simply state that both you and your analogy are wrong, It is just this sort of mindset, on both sides of the question that continues to cause friction. It is the impetus behind the CRNA push for the DNP. "That which diminishes the differences between our two camps only strengthens the CRNA argument" .The current AANA public relations effort is another step in the direction of public enlightenment of what CRNAs bring to the table. No longer will the ASA lay claim to our efforts because the patient assumes the man or woman at the head of the O.R. bed is an anesthesiologist. Bemoan your lot all you like, claim it is technology that is issuing in your collective demise, but the truth is that CRNAs have and continue to provide a superior product, constant vigilance. We WILL have to come to some accord in the future, but as long as Anesthesiologists contiue to grouse and hold themselves to be superior no accord is possible.Delete
It is dumb to compare a dental hygienist to a dentist. Hygienists are trained to clean teeth and not to pull out impacted wisdom teeth. A dentist does that. CRNA's are trained to perform all aspects of anesthesia, and therefore can do the most complicated anesthesia procedures just like an anesthesiologist.ReplyDelete
Go to medical school and become a physician. Then go through 4 years of Anesthesia residency. Then we can talk about equivalence. Ignorance is bliss.ReplyDelete
@Anonymous: Why spend all that time when u can become a CRNA and get the same $. Wait till a few years, both CRNA and MDA will be equals.ReplyDelete
Same pay? Who are you trying to kid?ReplyDelete
The Pimp daddies are losing control of dey Ho's...I deployed into combat zones several times and never had a MDA . Never needed them. #JigisupReplyDelete
Contracting CRNAs or chief CRNAs can make up to 300-400K. Pretty sure that's close to an MDA (starting) salary.ReplyDelete
Your comparing apples to oranges.
CRNA were NURSES before, on average 5 years (nationally) in critical care before applying to CRNA school. Yes it was as an RN, but we were involved in critical patients in the ICU. So with a 4 year undergrad (like med students), plus experience in the field (minimum is 1 year, but closer to 5 as a national average) and a 3 year (now mostly doctoral) CRNA program. That's 11 years in healthcare. You can downplay the "nurse" experience all you want, but as a nurse I taught residents ALL the time who were learning procedures, etc., etc.
Yes, I am not a physician and I will never claim to be one. Anesthesia was made originally for nurses to give. Look in your history books. Physicians (WAY back in the day) originally all wanted to be surgeons, and no one wanted to be at the head of the bed. People without degrees (usually women) were giving Ether to patients and being the "vigilant" provider we all need to be.
Nurses are still that in the CRNA role. I'm not saying I should be paid that same as an anesthesiologist, nor am I saying I have more schooling than one. But don't downplay my education/background or that fact that CRNAs are needed in the workforce. You can't do it all on your own, and the ASA's attack on out profession has driven the two sides apart.
a body of knowledge is finite capable of being learned by anyone with the intelligence....despite what initials follow their name.........MDAs and CRNAs are redundant in the workplace.period.......soon those that seek financial expedience will noticeReplyDelete
hey can u answer this if i give diamorphine epidurally will it go 1st pass metabolism in liver? cant understand the mcq :(ReplyDelete