Authors

  • Mitch Keamy Photo Mitch Keamy is an anesthesiologist in Las Vegas Nevada Andy Kofke Photo Andy Kofke is a Professor of Neuro-anesthesiology and Critical Care at the University of Pennslvania Mike O'Connor Mike O'Connor is Professor of Anesthesiology and Critical Care at the University of Chicago Rob Dean Photo Rob Dean is a cardiac anesthesiologist in Grand Rapids Michigan, with extensive experience in O.R. administration.

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Comments

Nursing Jobs in USA

Interesting site about the Medical Idiocracy.....

Disgusted by your statements

Honestly, you should be ashamed of yourself for spewing such absolute propaganda, fear mongering and lies.

Show me the evidence where CRNAs have caused all these things in practices? They dont exist and all the studies that do suggest otherwise.

I have no respect for anyone who makes up stories with which to scare the public and harden physicians against nurses without any basis in reality. If you want to know why CRNAs often have disdain for MDAs all you have to do is look in the mirror.

Haha

Earth to bow-tie anesthesiologist.....that was a ridiculously lame story - as high quality as any Bush/homeland security "it could happen" fear mongering.

kofke

this is an admittedly hyperbolic piece of fiction. however there have been events that very well could make much of what i predict a possibility:

AANA for years has been preaching that anesthesia is the practice of nursing not medicine and thus MDs are not needed

AANA has frontally assaulted the medical practice of anesthesia by actively working to decrease funding for anesthesia training programs. this has nothing to do with crna practice and everything to do with a tactical move to diminish or eliminate a political opponent

AANA actively opposes efforts to expand AA practice. AA's work under licences of supervising MD's unlike nurses

SRNAs in many programs are calling themselves residents....why would that be?

PHD CRNA's are increasing presenting themselves as dr so and so without clarifying their lack of medical training.

all of the major advances in anesthesia that have made it so safe have resulted from research performed in academic medical centers under the auspices of physicians.


I dont know why we cant just keep working together well like we have in past years. the AANA's work to expand scope of practice seemed a fair argument. However, I personally have become radicalized in my views when the AANA started activities that attacked the medical specialty of anesthesiology by so vigorously working against the teaching rule, something that really has nothing to do with CRNA practice and indicates other motives.

ak

Disgusted by your statements

Kofke

I appreciate you actually wanting to discuss the issue so I thought I would take the time to reply. Dont take offense to the "MDA" term, it isnt meant that way just shorter to type for me :)

You said:
"AANA for years has been preaching that anesthesia is the practice of nursing not medicine and thus MDs are not needed"

Well, it has been established in law that the practice of anesthesia is both medicine and nursing. This isnt an opinion, its the reality. I have never once seen anything put out by the AANA which has said that anesthesia isnt also the practice of medicine. I have also never seen anything put out which suggests that MDAs are not needed.

In fact, I would say MDAs are the ROOT of the science of anesthesia. Without physician scientists where would we be? I dont, however, agree that a physician is needed to provide safe and effective anesthesia.

You said:
"AANA has frontally assaulted the medical practice of anesthesia by actively working to decrease funding for anesthesia training programs. this has nothing to do with crna practice and everything to do with a tactical move to diminish or eliminate a political opponent"

The bill the AANA supports (6331) gives back money to BOTH SRNA and MDA programs. The teaching bill, if passed as the ASA wanted, would provide an economic incentive NOT to train SRNAs over MDAs. The bill as the ASA wanted it would change the pay scale for 2 MDA residents to 100% of the billing structure from medicare TO and MDA who is supervising the 2 rooms. However, if they were supervising 2 SRNAs they would ONLY be able to collect 50% of each case or a total of 100% as opposed to 200%. Clearly this is a financial disincentive to private anesthesia grps or hospitals if they collect all the billing. There is simply no other way to interpret it. 6331 will keep the playing field even where a supervising MDA OR CRNA for 2 SRNAs will also get 100% of the billing for each case up to 2 SRNAs.

Obviously this in NO WAY harms anesthesiology teaching programs but the ASA bill certainly would.

You said:
"AANA actively opposes efforts to expand AA practice. AA's work under licences of supervising MD's unlike nurses"

Of course we do. The ASA created AAs for no other reason than to oppose CRNAs with their own dependent provider by design. We see AAs as the ASAs attempt to replace us in the market. A perfect example is texas. There are literally THOUSANDS of MDAs waiting to be licensed in texas yet the ASA was pushing for AA schools to be open. Clearly this makes no sense.

AAs represent a group of people who cannot compete with MDAs for contracts and that is the goal of the ASA.

You said:
"SRNAs in many programs are calling themselves residents....why would that be?"

Where people get the idea that 'resident' means only doctor i dont know. However, the fact is its semantics. If i said resident nurse anesthetist what would it matter? For the record, personally, i dont see any reason to call SRNAs residents nor would i support it. I simply think it muddies the waters. However, i would never 'legislate' words which are general in nature as proprietary of physicians.

The same is true of the title Doctor. While i would never introduce myself as doctor in a clinical setting to avoid having to explain it, the title is not unique to one practice. In fact the title that is unique to you is 'physician'.

You said:
"PHD CRNA's are increasing presenting themselves as dr so and so without clarifying their lack of medical training."

Really? Please cite when you have personally seen this happen. I know MANY PHD CRNAs who have never used the title doctor in front of patients.

You said:
"all of the major advances in anesthesia that have made it so safe have resulted from research performed in academic medical centers under the auspices of physicians."

I agree.


You said:

"I dont know why we cant just keep working together well like we have in past years. the AANA's work to expand scope of practice seemed a fair argument. However, I personally have become radicalized in my views when the AANA started activities that attacked the medical specialty of anesthesiology by so vigorously working against the teaching rule, something that really has nothing to do with CRNA practice and indicates other motives."

I agree. I work great with my MDA colleagues. I also have no problem with indy CRNA practice. However, I do believe you may have it wrong when you suggest the AANA is trying to stop physician anesthesia programs or create a fiscal issue within them with 6331. It was the ASA that created a unilateral bill which would be anti-competitive via medicare reimbursement. The AANAs original bill included BOTH MDs and SRNAs. How is that trying to attack you?

Thank you for actually responding and explaining. I appreciate the discourse and look forward to your reply. If you can see my email id like to talk further, feel free to email me.

Mike

Mitch Keamy

Well, this is the "bow-tie anesthesiologist" chiming in, as distinct from Dr Kofke, my friend and blog co-author, who posted here. My feelings regarding nurse anesthesia were clearly articulated in a prior post "We have met the enemy and he is us..." You can find it here:
http://mkeamy.typepad.com/anesthesiacaucus/2008/02/we-have-met-the.html

I find this whole line of AANA/ASA discourse to be a little over-wrought, to be honest. But let me re-iterate what I have said before; without academic MDA's like Kofke and O'Conner, CRNA's can eventually expect to be paid a two dollar an hour differential from ICU nurse pay; after all, as the administrators will reason "they are only nurses..." CRNA's OWE THEIR PRINCELY (AND PRINCESSLY) INCOMES TO THE TIRELESS WORK OF ACADEMIC MD ANESTHESIA DEPARTMENTS (and so do I). So, pound away at MDA's all you want, BUT SUPPORT ACADEMIC ANESTHESIA.

Read my prior post if you don't get this...

gas man

Hi all,

congrats on a wonderful blog.

I am a trainee anaesthetist from the UK. The physician kinds (there is no other kind here)

was looking for a fellowship programme in the states a few months ago and was introduced to the CRNA vs MDA debate raging in the US these days. And oh my god!!! Do you guys fight or what...

this discussion to be sure is much more civilised than a few others that I have chanced across.

How did this come about, I mean, nurse incursion into a hardcore medical field...

Just curious

Gas man

http://content.healthaffairs.org/cgi/reprint/7/4/26.pdf

scary stuff this.

andrew kofke

thanks for the article reference.
Indeed, some anesthesiologists use their CRNA team as their ATM with little actual medical input. I should write a caustic article about that practice which I think fuels the whole controversy

ak

Mitch Keamy

Dear gasman:

there is a great story surrounding the rise of nurse anesthesia in the US. Whereas chloroform was initially the preferred agent in the UK and Europe, In the US it was ether.

Chloroform is an unforgiving anesthetic, in that it sensitizes the myocardium to the dsrhythmogenic tendencies of catecholamines. The initial tendency was to lighten the anesthetic depth in response to the deaths, assuming some direct chloroform toxicity, which only increased endogenous catecholamines.
Ether is very forgiving; since it is a respiratory depressant with rapid lipid uptake, patients who become too deep hypoventilate, lighten up as the ether redistributes to the lipid rich/well perfused muscle compartment, and self correct. Therefore it was reasonable to have the janitor or Sister (nun) slap a sponge on the patient's face and pour on a little ether. As a consequence, anesthesia seemed complicated to the Europeans, and simple to Americans. The rest, as they say, is history!

Shaking my head

"Therefore it was reasonable to have the janitor or Sister (nun) slap a sponge on the patient's face and pour on a little ether. As a consequence, anesthesia seemed complicated to the Europeans, and simple to Americans. "


Your Hubris and ignorance is infinite.

Shaking my head

oops correction...

Your hubris and ignorance ARE infinite.

Jo

Thank you Mike for writing such an objective and researched response to this fictional blog. As a nurse anesthesia student, my classmates and I wrote letters to our legislators regarding Bill 6331 and how it would negatively impact OUR education not MDA residents.

I am proud to be a nurse anesthesia student and when I do get my PhD I will NOT use the title doctor in the clinical arena because I want my patients to know who I am and the outstanding record of safe care my nursing profession has delivered since the 19th century. All the doctoral CRNAs I know feel the same way.

I appreciate BOTH the nurse anesthetists and anesthesiologists who work hard to educate me during the clinical day. Jo

Agreat CRNA

He probably wrote this while a CRNA was busy doing his case!

Jo

Dear Shaking my Head,
I think we all can agree that anesthesia in the United States and across the pond was rudimentary in the 19th century compared to today. I was wondering if you had ever heard of Alice McGaw termed the "Mother of Anesthesia" by Dr. Charles Mayo for her work as one of the first anesthesia providers in the United States. She worked at St. Mary's Hospital in Roch, Minn. She is credited with advancing safety in the operating room and the open drop inhalation anesthetic using ether and chloroform. Hundreds of physicians and nurses from across the world came to Minnesota to observe her technique in the 1890s.

Over the course of her career she wrote 5 noteworthy papers. One published in 1906 in Surgery, Gynecology and Obstetrics was entitled "A Review of 14,000 Surgical Anesthetics" (3:795). It reviewed 14,000 surgical procedures with nurse anesthetists that showed no complications or death attributed to problems with anesthesia or its application. I would not call this slapping a sponge on a patient's face.

I just wanted make you better informed of the early history of nurse anesthesia practice.

A recent review of over a 1,000,000 obstetrical anesthetics performed independently by the Health Research and Education Trust entitled "Anesthesia Provider Model, Hospital Resources and Maternal Outcomes" showed no difference in the safety record of anesthesiologists and nurse anesthetists. Glad we are all keeping up the good work and I hope we can constructively work together in the future to better patient safety.
Thank you, Jo

Jared

Hmmm.... interesting hypothetical points however; as well educated and trained individuals we must defer to the research of CRNA and MDA models of anesthesia. I am unaware of any valid research which would support your claims. We can and do work together in many environments where MDAs do not attempt to thwart or otherwise hinder a CRNAs practice and continued growth opportunities.

Shaking my head

Jo,

I was speaking to the "bow tie" MD. His hubris and ingorance is infinite as marked by his comment.

Jo

my apologies Shaking my head, my eye for sarcasm must be poor after night call :-).Jo

G. Peterson

What a bunch of bullshit Andy!! You really shouldn't be writing about CRNA's when you don't have the facts correct. I would think that someone as bright as you would be able to check out the truth before you post wrong information!!!!!!

G. Peterson

Would all of you please get your facts correct. It is a Doctor of Nursing Practice DNP......not a PhD that is the future of the Nurse Anesthesia Profession. With that, I can introduce myself to my patients as Doctor so and so, and I will be your nurse anesthetist....

The word Doctor does not originate from Medicine...A doctorate is an academic degree that in most countries represents the highest level of formal study or research in a given field.

MDA's are physicians but nurses, pharmacists, physicians, physical therapists, audiologists etc etc etc earn the title of Doctor!!!! It is so sad that I have to explain this to someone who has a doctorate as well. Apparently they didn't teach you very well in med school.

All you MD's on this kick to bash CRNA's are threatened for your jobs. You have to prove why you need to be involved. Well truth be told.....the majority of you are not needed. Just wait until HMO's and Health Care Facilities start saying enough is enough and begin weeding out MDA's, and therby reducing the cost of anesthesia health care!!!

Andy Kofke

Before I wrote this I pretty much thought the machinations of the AANA to expand CRNA scope of practice was a reasonable activity even if it did not agree with it. I was fairly apathetic about the whole issue. But when the AANA went after the foundation of academic anesthesology, the residency programs, I became really quite radicalized in my views about what has been going on and I came to believe the motives of the AANA were not limited to expanding scope of practice but rather to eliminating or seriously limiting MD anesthesia practice. Thus I concocted the fictional story of one possible outcome of their being successful.

By and large the CRNA's I have worked with over the past 30 yrs have been competent and collegial. I just urge everyone to think about the impact of limiting the growth of academic anesthesiology and the negative impact on everyone that could arise therefrom.

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