Wednesday, December 14, 2016

I Should Have Been A CRNA

Why didn't I go to nursing school and become a CRNA? After Medscape released its latest salary survey of advanced practice nurses, including CRNA's, that question should hang heavily over any student contemplating a medical career. The survey was completed by over 3,000 APRN's but only 290 were CRNA's so the sample size is very small. But the information that was revealed is still illuminating.

In 2015, CRNA's made an average salary of $176,000. That is up over three percent from last year. That is an income that would not be out of place for a primary care doctor. By contrast anesthesiologists' salaries, though at a much higher level, have remained static year over year, at around $360,000. But it's not just CRNA's that make good money. Other APRN's are also doing quite well. Nurse midwives and nurse practitioners both make over $100,000.

Besides the money, CRNA's also receive generous benefits. According to Medscape, 91% of APRN's receive paid time off. Three fourths get an education allowance and liability coverage. Many are reimbursed for society membership dues and paid family leave.

Going through nursing school and APRN training is much more affordable than medical school. The average medical school debt upon graduation is over $150,000. Some owe a lot more than that. In many parts of the country that is enough to buy a decent house. By contrast, nursing students are in debt for about $30,000 upon graduation. Consequently, only about a third of APRN's still have student loans outstanding.

Finally, what is the best reason to become a CRNA instead of an anesthesiologist? The total lack of accountability. Even though the AANA is fighting hard to allow their members to practice independently without the supervision of physicians, I suspect that many of them secretly prefer being directed by an MD. If any anesthesia complications arise, they can easily point their accusatory fingers at the anesthesiologist and say they are simply following orders from the physician. They are not held responsible far any adversities in care.

So to sum it all up, CRNA's make a very decent salary, with lower student loan debt, receive better benefits, and are not responsible for their actions. Sounds like a pretty decent living to me.

21 comments:

  1. Oh come now.

    A quick review of case law shows that regardless if a CRNA works with an MDA they are certainly responsible for their actions.

    https://www.dropbox.com/s/iaz6ilkagbnztrx/LifeLinc_WhitePaper_Surgeon_Liability_2015_web.pdf?dl=0

    https://www.dropbox.com/s/5n0u1n8dhhvoc8u/NO%20Vicarious%20Liability%20of%20a%20Physician%20for%20the%20Negligence%20of%20Othe.pdf?dl=0

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  2. Let's not forget the hours worked for that money. CRNAs work 40 hours/week or less. MDs tend to work 60-65 or more.

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    1. Yah, cause none of the academic MDAs work less than 60-65?

      I dont work 40 hours a week bud. I work till the cases are done.

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    2. yeah they just happen to end at 2pm

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    3. No that's not the case. We do nearly 14000 cases a year with 12 of us. Lots of 24 hour stand up days. 2 rooms running till 9 pm and 2 till 6. On call all night and no pay for it. All fee for service..

      'You don't know what you don't know' Mr too
      Afraid to use you name

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  3. Yes anyone can be named in a suit. I don't think that's the point the author was making. I think you would agree that physicians are less able to shirk responsibility, while in at least SOME instances aprns are still able to use the captain of the ship concept to save face. In any case, I partially agree with you, because if the current trend continues, many more APRNs will start to be named. However, statistically, APRNs currently enjoy a much lower relative risk of lawsuit. I think you would also agree with the author that physicians put much more at stake with their debt and years of training, which makes the current system unfair if the rewards of being a physician are not much greater then being an aprn.

    That is just my opinion. From an outside point of view physicians seem to be getting a raw deal. If you're a pcp making just as much as a PA or APRN why wouldn't you just go to nursing school? See why medical student would avoid primary care?

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    1. Here are my comments:

      When it comes to liability 46.7% for claims against anesthesiologists went to litigaton, of those cases 54.1% were dismissed by the court and less than 2% of those claims underwent a trial verdict (jamanetwork.com/journals/jamainternalmedicine/fullarticle/1151587). Most are settled out of court without wrong doing. So we are talking about a small number of cases really. Of those cases, and ive reviewed many, there are none im aware of where an MDA was sued for the actions of a CRNA which they were not aware of. So the statement that there is liability by the MDA or surgeon for the actions of a CRNA where the hospital policy does not implicitly state these individuals are legally liable for the actions of a crna (which they never should), is not accurate in case law.

      The evidence for this i posted already where CRNAs have been sued for their own actions and the MDA and surgeon being dropped. If vicarious liability existed these outcomes would be impossible.

      When it comes to surgeons working with independent CRNAs or MDAs A physician is not automatically liable when working with a nurse anesthetist; nor is the physician immune from liability when working with an anesthesiologist. Courts have held surgeons liable for the negligence of anesthesiologists when the surgeons had control of the anesthesiologists' actions. In Schneider v. Einstein Med. Ctr., 390 A.2d 1271 (Penn. 1978) and Kitto v. Gilbert, 570 P.2d 544 (Colo. 1977), the courts found the physicians liable for the negligence of anesthesiologists because the physicians were in control of the anesthesiologists' actions. The question, as in cases of a physician working with nurse anesthetists, is whether the physician was in control of the acts of the anesthesiologist.

      There are many cases in which courts have found that the surgeon was not in control of the nurse anesthetist and, therefore, not liable for the negligence of the nurse anesthetist. E.g., Cavero v. Franklin Benevolence Soc'y, 223 P.2d 471 (Cal. 1950); Fortson v. McNamara, 508 So.2d 35 (Fla. 1987); Franklin v. Gupta, 567 A.2d 524 (Md. 1990); Hughes v. St. Paul Fire and Marine Ins. Co., 401 So.2d 448 (La. 1981); Kemelyan v. Henderson, 277 P.2d 372 (Wash. 1954); Parker v. Vanderbilt, 767 S.W.2d 412 (Tenn. 1988); Pierre v. Lavallie Kemp Charity Hosp., 515 So.2d 614 (La. 1987); Thomas v. Raleigh Gen'l Hosp., 358 S.E.2d 222 (W. Va. 1987); Sesselmen v. Mulenberg Hosp., 306 A.2d 474 (N.J. 1954).

      Moreover, numerous cases hold that mere supervision or direction of a nurse anesthetist is insufficient to hold a physician liable for a nurse anesthetist's negligence. See, e.g., Sesselmen v. Mulenberg Hosp., 306 A.2d 474 (N.J. Super. Ct. App. Div. 1973) (error for trial court to instruct that obstetrical surgeon could be liable for nurse anesthetist's negligence where obstetrician never exercised control over nurse anesthetist and nurse anesthetist merely received obstetrician's instructions concerning the work to be performed); Baird v. Sickler, 69 Ohio St.2d 652 (1982); Foster v. Englewood Hosp., 19 Ill. App. 3d. 1055 (1974); Elizondo v. Tavarez, 596 S.W.2d 667 (Tex. 1980); Whitfield v. Whittaker Mem. Hosp., 210 (Va. 176 (1969).

      It is clear from the case law that in order for a physician to be liable for the acts of the anesthesia administrator, the physician must control the administrator's actions and not merely be supervising or directing the administrator.

      In a January 1988 report of the Center for Health Economics Research (CHER), an independent Boston-area based research organization that analyzes and evaluates health-related policy issues, CHER concluded that "both legal doctrine and case history (as reviewed by the AANA and ASA) do not indicate courts to hold surgeons liable more often when they work with nurse anesthetists than with anesthesiologists."

      see next post

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    2. Post 2

      If that was not enough evidence even the ASA legal counsel agreed in their newsletter to their members: American Society of Anesthesiologist Newsletter. Judith Jurin Semo, Esq (2000). Surgeon Liability for Nurse Anesthetists: Fact or Fiction?

      Where they stated:

      "The controlling factor in determining whether a surgeon is to be held accountable for a nurse anesthetist's actions is whether, based on the facts of the case. If not, the surgeon is likely not to be held accountable for the actions of the nurse anesthetist or adverse patient outcomes resulting from the administration of anesthesia."

      Now when it comes to training time and debt while i understand that may be upsetting to them that I make more than some that isnt my issue nor should it dictate salaries or legislation. All physicians are aware what their salary range is likely to be when they choose a specialty as are all APRNs. It is nor more acceptable for an FNP (which i am as well) to be upset with me for choosing to become a CRNA and make more than it is for an FP MD to be upset with an MDA for choosing anesthesiology. Pay is what the market bears. If the market does not value FP FNP or MD more than anesthesia and i or my physicians MDA colleagues get paid more than they do they have the freedom to go back and retrain. It isnt my fault nor should I be punished for choosing well.

      If a med student is avoiding primary care because of a perceived low income for the work (tho for that pay they arent taking 13 days a call a month like I am and often in the OR till late at night), then that is market supply and demand at work. When that happens someone who is willing to work for that pay (FNPs) will fill the gap and meet the access to care needs. If the research shows, and it does, that outcomes are equivalent between the providers then this is a win for the American people. Same great care held to the same standard (there is only one standard for all practitioners in every specialty and we are all held to it equally), for less cost to the system (lower cost to train, train in less time, no cost of tax dollars (GME MONEY) to the public). Seems like a win to me?

      It is a free country. If med students do not value the lifestyle of primary care over the financial benefit then I agree, they should choose another specialty and that is not a bad thing or wrong but we cannot be upset when someone WILL do it for that lifestyle and pay to fill the need. Right?

      Great discussion! I appreciate your professionalism!

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  4. If your supply and demand argument is correct at the same time as total outcomes being the same, then you are correct that the market should demand more mid-level providers. I think the reality is that it simply does not. Personally, I don't want my daughter ever seeing an APRN despite feeling taken every time we go to see the MD Pediatrician. It's because I do believe their training means something, and it's second to none where my daughter's life is concerned.

    I guess my question to you guys is do you value the role of physicians, or has the market replaced them? Just being able to do things that a physician does isn't enough for me--do you think as a physician does? It would seem that you think everything that a physician does can be replaced by a nurse, but the only masters of anything useful that I have ever met were humble about their abilities.

    I may just be a big doubter, but I doubt that nurses know everything that a residency trained physician knows with their fewer hours of training. I doubt that the outcomes are truly equal on every single metric, measured or unmeasured, but that it just so happens that the metrics that are measured are ones that make hospitals the most money (again, reducing your argument to a supply-demand point). Anyway, I think nurses are valuable members to healthcare teams, and they have their role. It's really hard to truly replace people even if you reduce them to "hours of training" or "tax dollars". For example, why don't hospitals just replace nurses with janitors if they both meet the standard for mopping floors well? Seems like a win to me?

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    1. Kevin

      I see an APRN, My kids do, My wife does, Ive put to sleep multiple physicians, public figures, kids of physicians and hospital administrators and i was put to sleep twice by CRNAs all without an MD. None of them or my family, felt the care was inferior or less than. In fact, we all choose to have it.

      So where my kids (7/9/15) are concerned, my wife and myself we goto APRNs, do you suggest there is risk there? Cause there isnt. The same BS argument was made about DOs in the past.

      So as someone who knows the difference in training, and has personally experienced it I can tell you the difference is nonexistent. You assume it is but the fact is there isnt any evidence, real or experiential, showing a difference in care or outcomes. So what you are doing is making an assumption without any reason except you "THINK" it makes a difference.

      As for your question "do you value the role of physicians, or has the market replaced them?" my answer is I value my physician colleagues highly and count many as some of my very best friends. However, that does not mean I do not compete at the same level as them, which I do.

      You asked:

      "Just being able to do things that a physician does isn't enough for me--do you think as a physician does? "

      Im not a technician I am a clinician. My outcomes are just as good as anyone else's. Seems to me THAT is what matters. Right? Not the initials.

      "It would seem that you think everything that a physician does can be replaced by a nurse"

      Not everything today nope. There is a list of things speciality physicians do which APRNs do not. However there is also a list of things which APRNs do just as well as their physician counterpart in every metric.

      As for 'humble', when someone tells you that you are "less than" without any evidence, lobbies against your profession to restrict and limit them without any evidence and fear mongers the public it does not take long to address these attacks with equal force.

      You want to know why they lobby against us? Here it is summed up in a quote by Upton Sinclair:

      "It is hard to convince a man of something when his salary depends on him NOT being convinced of it."

      You said:

      "I doubt that nurses know everything that a residency trained physician knows with their fewer hours of training. I doubt that the outcomes are truly equal on every single metric, measured or unmeasured,"

      Every metric is from STUDIES trying to determine outcome differences not hospitals. So you are wrong there. Also hours of training does not imply proficiency, competence or superiority does not take long reviewing closed claims data to see that.

      Want to review a metric which is not biased? Look at liability insurance. CRNAs pay 7000$ a year for liability insurance regardless if they are working independently or with MDAs. Does not change. One would assume that the actuaries who are apolitical and looking to protect their company from undue risk would require a premium for independent CRNAs if they were less safe, had worse outcomes or there was a higher risk... yet they dont. To underscore that further, when a surgeon works with an independent CRNA they DO NOT PAY A RIDER on their liability insurance. Now if their was a risk you can bet their liability insurance would factor that into claims. Yet they do not even ASK this because it does not. Why? Because there is no increased risk, thats why.

      The key here is this. When it has been proven over and over again that APRNs provide equal care with equal outcomes compared to their physician counterparts (such as MDAs v s CRNAs or MD Primary care vs FNPs) then the take away should be that physicians training isnt needed for these roles and they should move into something which requires their expertise. When it was discovered that MDs weren't needed to start and manage an IV, they stopped doing it. This is one of many examples

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    2. Let me leave you with some quotes from some very highly respected MDAs who disagree with you.

      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...."

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    3. I'm not one to say that Stoelting is wrong about outcomes. However, I find the argument that outcomes are all that matters to be a form of reductionism. This reductionist argument is one that any hospital administrator will use to justify their decisions...they definitely only see physicians or nurses as technicians, and think in terms of outcome = income. They also wont think twice before replacing someone with a robot.

      I used to be a data analyst, and I know how the studies you mention are formulated, and I am not saying the studies are wrong...however, it is up to individual human beings to interpret what those studies mean, and I will say with confidence that during my duties not a single one of my studies was interpreted neutrally or cautiously by any businessman in the room. Therefore, I would interpret Sinclair's quote to mean that people will think what most supports their own worldview, and APRNs are no different than physicians in that way. I left that business because we have become fascinated with measuring and comparing things, and to be honest most of the time we either don't know why/what we're actually measuring or there's an ulterior motive (Just look, on the news there's a study differentiating Men's and Women's performance as clinicians and people think it means something!). Very rarely, if ever, are all of the relevant variables measured, and many of these variables cannot be measured. It's those unmeasurable variables that have me bringing my daughter to a Pediatrician, not the outcome ones. Your language that anything has been "proven" makes me very suspect, but again I don't really mind that CRNAs are equivalent in terms of outcome (I would actually applaud it). If you think that "outcome" is all that matters, then you have made up your mind and I cannot change that.

      I think it is most likely true that the list of things speciality physicians do (and which APRNs do not) could easily be performed by APRNs, but they do not because those procedures are guarded for income reasons. That is, the distinction you draw between physicians and nurses is in "what they do", not "what" or "how" they think. Actually, what worries me the most about your position is that you don't think training standards mean anything, and that anyone should be able to walk into any specialty with ease without going through the breadth of medical training or the difficulty of residency. And it's not at all clear that this is a safe opinion 100% of the time (primary care APRN becoming a neurosurgeon?) I suspect that the next study that I see forwarding this opinion will suggest that a residency doesn't matter all that much if at all, or for that matter studying live human beings to learn clinical medicine.

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    4. Hi kevin

      Outcomes ARE important and it is what PATIENTS care about. If the outcomes of CRNAs in M&M were worse, you can bet that the ASA would be touting that on the highest mountain to patients so that there would be an outcry against us. That isnt happening because the outcomes are the same. It isnt reductionist, its reality.

      Would you pick a surgeon who had worse outcomes who was an MD as opposed to one who was a DO with better ones? Of course not. Outcomes matter. They are the metric by which we are ALL judged by equally.

      Sinclairs quote talks about someones vested financial interest blinding them to reality. CRNAs do not fin financially benefit from my statements. We work for less in every situation that an MDA could work. Significantly less. However, When an MDA "medically directs" 4 CRNAs from an office chair, they bill 50% for each of the 4 cases. That is quick math brother. When medically directing 4 CRNAs they make 200% of what they would if they did cases themselves. We are incentivizing MDAs NOT to do what they were trained to do and restricting CRNAs from doing it. To everyones detriment EXCEPT the MDAs who have a financial vested interest in keeping the status quo and diminishing CRNAs capabilities. So no, i dont see how sinclair's quote could ever be interpreted the other way.

      I find it interesting you think that APRNs and Physicians think differently when doing the same job. How do you eve qualify that statement? By your own admission you have NEVER been treated by an APRN. So how would you come to such a conclusion when you have no evidence, basis or even reasoning for it?

      You examples about training simply do not make sense. MDAs are trained in one way, APRNs are trained in another, BOTH are qualified, standardized and intensive educational structures. It isnt as you suggest here that some random RN is an APRN one day without standards. They are simply 2 ways to get to the same endpoint and the OUTCOME of the training is the same. It is the same in EVERY METRIC there is for over 75 years for APRNs and over 150 for CRNAs. Through hundreds of studies about APRNs/CRNA vs Physicians there are no differences. Do you believe that if there were negatives (of ANY KIND) to APRN practice it would continue today? Hospitals are one negative patient experience, one lawsuit, one bad risk, one bad outcome away from an event which would wipe out any cost savings of APRNs and yet the practice continues because these things do not happen anymore to APRNs than they do to physicians.

      So to come back to your minimizing of outcome studies to determine safety and competence, what do you think is more important than that exactly? You do not seem to define it but make a bold statement that outcomes, M&M and every other metric we study in healthcare to determine safety, competence and capability do not matter much.... if so then what does? "How someone thinks" isnt a valid answer. Define it. Show me the evidence. over 150 years of CRNAs working independently and 75 of APRNs doing so defies your statements.

      As thew saying goes.

      What can be asserted without evidence can be DISMISSED without evidence.

      AND

      Extraordinary claims require extraordinary evidence

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    5. Mike,

      I never said that outcomes aren't important. I said they aren't EVERYTHING that's important. It's a great idea to ask whether training has an impact on outcomes, and I agree with you that "outcomes" are important to patients, but I beg you to consider that outcomes mean different things to every patient. Some are happy to make it off the operating table alive, while others are unhappy due to a minor complication. At the same time, healthcare isn't a discrete experience (or even a set of events) to be independently measured as you describe it. It may only appear that way in the setting of acute care. What you should have taken from what I said is that outcomes are difficult to measure accurately and easy to misinterpret.

      To use your own example, I don't believe that patients use only statistical information when choosing physicians. Personally, I wouldn't undergo surgery from a physician that I do not trust, and I emphasize that trust is not a variable that can be measured objectively against everyone else. So once again, outcomes are not the ONLY factors that matter.

      As a CRNA you are making a six figure salary. I think that's a good thing because I think what benefits nurses will come to benefit patients, and even physicians in the long run, and that health care practitioners should be fairly rewarded for difficult work. I think the situation you describe (some mutation of the anesthesia care team) is a function of the system you practice in, which ironically is a system that convinces people that healthcare outcomes can be adequately measured and commodified. I do not believe that what you describe is an intended outcome of the system that insurance companies have directed to build with physicians. I'm sorry you feel that you are not being reimbursed adequately in this system. However, physicians interests in maintaining this system has weakened as APRNs seek independent practice rights (I have mentioned that it is something that bears hard on medical students). I do not believe it will ultimately benefit patients by giving them greater access to care, or reduce our country's healthcare spending. More likely it will fracture the relationship that physicians have built with nurses over the past century, and disrupt the status quo that insurance companies have come to enjoy.

      You make fine points, and I could spend a lot of time debating those points, but we wont get anywhere since it looks like this is devolving into a communication about my opinions. In my experience as a scientist, there is no objective judgement that can be made about the value of different healthcare providers. For example, when I asked if you valued the role of physicians, you did not offer your position on what exactly physicians offer. I do not expect that your position on what physicians offer is at all objective. Even if it is based on "outcome" measures, that is not an objective position, because as I mentioned above the experience of healthcare is not discrete, and measuring it in this way is artificial and dependent. Leadership, responsibility, and professionalism mean something completely unique in my understanding of the role of a physician when compared to the nursing profession. Functionally, however, this is unacceptable to the decision makers at the top of the healthcare pyramid (not physicians). They want life to be grounded in the black and white of "objective" evidence so they can feel better about their decisions.

      Always professional,

      Kevin

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    6. Hey Kevin

      I have really enjoyed our banter! You are intelligent and interesting to debate with.

      It is likely we see more things the same than different. One thing we appear to see differently are roles. I take the ultimate responsibility for anesthesia where i am, im the leader for that. I do not think physician s have some monopoly on those concepts you mentioned and they are as transient with them on an individual level as they are with everyone.

      Leaders are leaders.

      Having said that Merry Christmas and have a Happy New Year Kevin!

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  5. I love it when these insecure, mid-level providers leave long, multiple paragraph missives about how good they are and how they are equivalent to physicians. Sheesh! Talk about insecurity!

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    1. You mean prove with evidence reality?

      Or should I just take your word for it?

      Oh and PS. there is no such thing as a 'midlevel'. That would presume I dont do everything as well as my physician colleagues. Which simply isnt the case. Anesthesia has ONE standard no matter what your initials are and we are ALL held to it.

      But thanks for putting in your 2 cent attack.

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    2. I don't really have a dog in this fight, but from a patient's perspective, I have not had good experiences with CRNA's. I much prefer regional or spinal anesthesia when having surgery. A CRNA tried to talk me into a general for an abdominal procedure that I knew could be done with a spinal. After my lengthy discussion with the CRNA and being labeled a "control freak" because I did not want to surrender consciousness an MD appeared on the scene and readily agreed to a spinal. I was fully alert and chatted with him the entire procedure about how CRNAs lack experience with regional and spinal anesthesia.

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    3. Midlevels are touchy about that term. They don't know what they don't know, it is not their fault. Much like touting their ICU "experience" as being somehow sufficient to then skate through a 3 year training program to make them magically ready for independence.... It is disgusting.

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    4. Wow you are clueless 'keyboard tough guy'

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  6. CRNAs do almost the same job as an Anesthesiologist, but in much smaller faculties. Anesthesiologist tend to work in larger hospitals while CRNA's work in smaller hospitals, clinics, dentists, and other places with smaller procedures.

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