Questions for/by an anesthesia resident

[AnesRes2014]

In the name of open dialogue and communication, and in the vein of MilMD's stickied post, I started this thread to answer/ask questions that I've noticed in my first 30min worth of browsing forum topics. To clarify, I am a first year resident (PGY-1), so my only anesthesia experience has been my fourth-year anesthesia rotation and a year working as a clinical research coordinator before med school, so my answers on anesthesia-specific topics will be limited. But questions about medical school, intern year, and the whole residency application process are certainly fair game.

For starters:

Q: Why do some anesthesiologists not like to be referred to as MDA?

2 reasons. 1) The degree on our diploma is MD, just as it is for a family doc, general surgeon, pathologist, etc. B) MDA (to me) implies that our training was somehow different than theirs.

Q: What is intern year like? (prompted by a post that intern year more or less = nursing school)

A: I can only speak specifically about my intern year (and generally about other types that I looked into), and I can obviously not speak to nursing school at all, but I doubt seriously that the two are even roughly equivalent. Not in a pretentious-sounding way, just in a factual "they are very different" kind of way.

Let me know if there are any other burning questions out there.

[maliggs]

I would venture to say (and I can only speak from MY experience) that a first year intern has NO WHERE CLOSE to the same experience as an RN working in a high acuity ICU.

I worked in a Level 1 SICU/Trauma unit for quite a few years, when we had an intern to call, we knew that we'd be calling the shots when it came to managing the patient. But I worked in a place where if you weren't a good enough RN, you'd get fired. Perhaps it's not that way everywhere. Nursing school isn't very hard in my opinion. There are plenty of people who made it through nursing school and I hope they never take care of me. However, once you decide to become an ICU nurse, there is an entire different game to be played. My ICU training included a 12 week ICU course (computer based and interactive), as well as 3-6 months with a preceptor. And THEN you'd get easier patients....it's not until after your first 1-1.5 years that you'd get sick patients on your own.

Also, I don't use the term MDA when I'm speaking about one, I only use it here when I type to differentiate who I'm talking about. It's more shorthand than anything else (in my opinion).

[SuccsDrugs&Rocuron]

is this true?:


Posted here, http://forums.studentdoctor.net/showthread.php?t=770846
----------------------


Attendings & Residents: Take the pledge

Time to man up and take the pledge:
1. NEVER teach a CRNA or SRNA anything. If they ask "why/how did you do x/y/z", politely say "i dunno, just cause".
2. Do NOT allow them to do any Regional blocks. Maybe a spinal, but that's very generous. No ultrasound blocks or epidurals.
3. Do NOT allow them to do any Invasive lines. Maybe an arterial line, but that's generous.
4. STEP UP and take call or stay late if needed. Don't sell out our profession by being a "lounge lizard".
5. DONATE to the ASAPAC every year. Not just the minimum. Laws and policies are influenced by the amount of political donations.
6. EDUCATE your fellow attendings/residents/medical students. The more people know, the better.
========

[RAYMAN]

Intern year equivalent to nursing school? Seriously? That's almost funny. A year or two in ICU, perhaps.

[AnesRes2014]

Is what true, specifically? As I'm sure everyone here is acutely aware, there is a wide variety of attitudes/opinions towards CRNAs from physicians, just as there are a wide variety of attitudes/opinions towards physicians from CRNAs. From my personal standpoint, there are 2 competing forces here. Firstly, I am all about everyone furthering their knowledge as much as possible, so in general I am all for as much teaching as possible. I also think it promotes a team atmosphere. But on the other hand, there is a subset that is going to take that knowledge and then try to turn that around and use it against the teacher. So I fully understand the sentiment that is expressed on the board.

[Anthony]

Welcome to the site. I commend you for your willingness to answer questions.

I would ask that all participants remain civil and.... especially for the opportunity of learning/sharing ....keep an open mind.

[AnesRes2014]

It was a CRNA that made the comparison.

The point is, I don't think equivalencies are possible. Nursing school to medical school. Post-nursing school training to post-medical school training. Trying to frame arguments in those terms, then, is pointless.

[BuckeyeRN]

Welcome!
Even though we may (or may not) disagree on some issues I look forward to seeing a different viewpoint here.

[Anthony]

Do you mind sharing your transitional intern experience (eg. type of rotations, clinical expectations, general comments) - in order for readers to appreciate your POV. Thanks.

tone

[AnesRes2014]

Thanks. I am fully aware of the possibility of such a thread's potential to decline rapidly. It's the same way over on SDN. Internet posters will be internet posters. It just seems like there are a lot of assumptions made between the two groups, and if we can minimize those, everyone will be better off for it.

[BuckeyeRN]

I can agree that nursing school is not equivalent to medical school.

However a bachelor's level nursing school (going from my own experience here) requires many of the same basic science courses that you would need to get into medical school. There are some exceptions such as organic chemistry, physics, etc but I know of at least two nursing schools that include some organic chemistry into their degree as well.

Then after you went to medical school you received a much more in depth study into the field of medicine. Some of that is applicable to you now as an Anesthesia resident, some is not.

Edited to add: When I graduated from nursing school I worked full time in an ICU setting for 3 years before entering CRNA school, some work more some work less and we all gain and must show a certain level of knowledge (through experience, interviews, CCRN certification, etc) before being accepted into CRNA school. I would never suggest anyone applying for CRNA school until they are comfortable and capable of taking care of the sickest patients they see and comfortable discussing the goals of the treatment and the "why" behind what we are doing with the doctors for those sickest patients that we are taking care of.

While I am in CRNA school I am getting a very in depth knowledge base of the science, medicine and knowledge necessary to provide anesthesia. We use the same textbooks that medical schools use, and have Phd's lecturing us just as you did.

Then we have our clinical training whereas you have your residency. Both are similar in how they teach us the application of all the knowledge we have accumulated. We both gain more autonomy as we go through it. Both experiences are better or worse depending on where it occurs.

We both then need to pass a standardized exam to recieve our certification.

Then we can both practice independently or part of a team depending on our choice. It has been shown in multiple studies that the end result of either a CRNA or an Anesthesiologist (or MDA for shorthand but since you said you'd prefer not to be called that I'll try to remember) independently giving the anesthetic or a CRNA and an anesthesiologist giving the anesthetic together in a ACT model have the same outcome.

So while you undoubtedly know more medicine then I will (and you can have all that extra knowledge), in the realm of anesthesia our outcomes and knowledge base are the same and we are both completely capable of doing the same job equally as well.

[Esper]

What made you decide to go into anesthesia?

What type of practice are you looking to work in when you are an attending: ACT, MD only; PP, academia?

I can somewhat appreciate why you dislike the term MDA, but do you truly feel that it's use is meant to be derogatory? Perhaps it's just shorthand as others have said.

Last question, do you really feel that all those studies claiming CRNA solo safety, the opt out MM study, and the new IOm report have no merit at all? I'm not asking if you fully agree with them, but do you really think they are just coming out of left field with nonsense?

ETA: oh and Welcome! I look forward to a long standing collegial relationship!

[BuckeyeRN]

Thanks. I am fully aware of the possibility of such a thread's potential to decline rapidly. It's the same way over on SDN. Internet posters will be internet posters. It just seems like there are a lot of assumptions made between the two groups, and if we can minimize those, everyone will be better off for it.

I completely agree and hope this doesn't go that way.

[AnesRes2014]

Absolutely.

Anesthesia residencies are 1 of 2 types: categorical and advanced. Categorical programs start with PGY-1, and then follow it with CA1-3 years at the same institution. Categorical programs are typically more like transitional years as you alluded to, in that there is a mix of medicine, surgery, pediatrics, ED, ICU, and elective time. My program is fairly balanced: I will do a month to 6 weeks of: surgery, SICU, medicine, peds, PICU, ED, anesthesia, electives (anesthesia-related, in my case). Some categorical programs will lean more towards surgery or more towards medicine.

If you do an advanced program, you start in your CA-1 year and are required to find a PGY-1 year on your own. This can be a dedicated transitional year (which are more competitive), or a prelim surgery or medicine year. Big picture, there is a push for more categorical programs as this allows more standardization for a program's CA-1s to start at the same level.

Clinical expectations vary depending on the service/attendings/time of year. In general, an intern is expected to make independent lower-level/non-acute decisions, and at least temporize and develop a plan for higher-level/acute decisions until an upper level resident or attending is available. That said, an intern at the end of PGY-1 is going to be much more competent than an intern beginning PGY-1.

[Skeebum]

Welcome to the site Res.


I can somewhat appreciate why you dislike the term MDA, but do you truly feel that it's use is meant to be derogatory? Perhaps it's just shorthand as others have said.


I too think it's just short hand, but I really don't know where it started.

On the bright site, we have yet to refer to Doctors of Osteopathic medicine who specialize in anesthesia as DOA :laugh::laugh:

[MmacFN]

Hey dude, welcome to the website!

Personally, I am glad you are here. Let me add, you will find some extremist personalities here just like on SDN but just ignore them ;)

You mention the MDA thing but I think you are only really getting this information from SDN. Where I trained the Anesthesiologists called themselves MDAs and so did everyone else. I know when I use the term it is simply a short way to write/say a long word similar to CRNA as opposed to Nurse Anesthetists (or the whole frikin thing which i can never be bothered to write !)

I can tell you definitively that I have never met a CRNA or "MDA" or anyone else who said the term "MDA" in anyway that was negative, lesser than other MDs or to mean anything that a short way to say the word Anesthesiologist. I know its odd since it only exists in Anesthesia and really, noone says "DOA" (though that would be hilarious) but i can assure you that contrary to popular statements on SDN, nothing is meant by it. In fact, the first time i heard it was from an Anesthesiologist (see that was alot of letters :)).

Hope that diffuses what people mean when they say MDA, just easier to type and not a negative thing except in the minds of people on SDN.

Again, thanks for being here ;)



In the name of open dialogue and communication, and in the vein of MilMD's stickied post, I started this thread to answer/ask questions that I've noticed in my first 30min worth of browsing forum topics. To clarify, I am a first year resident (PGY-1), so my only anesthesia experience has been my fourth-year anesthesia rotation and a year working as a clinical research coordinator before med school, so my answers on anesthesia-specific topics will be limited. But questions about medical school, intern year, and the whole residency application process are certainly fair game.

For starters:

Q: Why do some anesthesiologists not like to be referred to as MDA?

2 reasons. 1) The degree on our diploma is MD, just as it is for a family doc, general surgeon, pathologist, etc. B) MDA (to me) implies that our training was somehow different than theirs.

Q: What is intern year like? (prompted by a post that intern year more or less = nursing school)

A: I can only speak specifically about my intern year (and generally about other types that I looked into), and I can obviously not speak to nursing school at all, but I doubt seriously that the two are even roughly equivalent. Not in a pretentious-sounding way, just in a factual "they are very different" kind of way.

Let me know if there are any other burning questions out there.

[stanman1968]

I believe that as an experienced ICU nurse you are held to a similar ( not exactly the same standard) as an intern. Pt has problems identify and make corrections and hold the fort until the MD shows up, as for the non acute decisions sure all of the time, the real difference IMHO is ownership, as an ICU nurse you learn there is someone to make a final decision unlike an intern or resident and this mindset is the hardest thing to unlearn.

[ADMIN]

I expect that everyone will be respectful to this physician as you should be to anyone. He has, clearly out of an interest in open discussion come here to learn from each other. This is something we should all be promoting and working toward as opposed to against.

Lets set an example.

Thanks you, AnesRes2014 for taking the time to actually have a civil discussion. You are most certainly welcome here and i applaud your willingness to do it!

This thread is now a sticky

[MmacFN]

Well...let me play devils advocate.

To be fair this depends upon the facility.

Many facilities (particularly teaching ones) have various levels of people to goto who are in house and there for that purpose. They can range from interns, PAs and NPs to increasing levels of residents up to attendings who are in house. In these environments many nurses become protocol monkeys who often do not know why they do things and have little decision making ability. Having said that, this isnt all facilities or all nurses in these types of places and often not people who get accepted into anesthesia school.

Now, many of us worked in places where we functioned at varying levels and it was expected. This included, but was not limited to autonomous decision making, initiating intervention and straight management of sick patients.

I do not blame residents and attendings for seeing nurses in the role they do because at the facilities where they train these things would be unheard of or rare. The fact is however that the majority of rns in the country work at facilities where they are expected to work in this manner and know 'why' they are doing what they are doing. Most residents and other learners never see this tho so why would they think it was any different.

This is also true of attendings and residents who work in a place where the CRNAs are all gone at 3 pm and never do anything without calling the attending. That would annoy the shit out of me if i was a resident as well and it would make them seem like pre-madonna 'assistants'. They never see places like where most of us work (most jobs are not in academic centers) where it is all much different.

I am just trying to see it all from their POV as opposed to ours.


I believe that as an experienced ICU nurse you are held to a similar ( not exactly the same standard) as an intern. Pt has problems identify and make corrections and hold the fort until the MD shows up, as for the non acute decisions sure all of the time, the real difference IMHO is ownership, as an ICU nurse you learn there is someone to make a final decision unlike an intern or resident and this mindset is the hardest thing to unlearn.

[Summitk2]

Q: Why do some anesthesiologists not like to be referred to as MDA?

2 reasons. 1) The degree on our diploma is MD, just as it is for a family doc, general surgeon, pathologist, etc. B) MDA (to me) implies that our training was somehow different than theirs.

Welcome, AnesRes.

But.... I believe your training IS different, right? (referring to above in bold)

I agree with others, that it's just a qualifier, and not a derogatory term. I believe "those" MDs are called other names ;)

[JadamR15]

AnesRes,

Hey, welcome!

To help prevent degeneration of the thread:

You should know that some of us are OK conversing with you, despite the likelihood that you disagree with many CRNA/SRNAs regarding those professional issues that have divided our professions so deeply, and for so long. I'm sure we are both familiar with the carefully worded arguments from both sides, so reviewing thoughtlessly them would be a moot point. Thankfully, agreement is not a necessity for learning or for dialogue.



A: I can only speak specifically about my intern year (and generally about other types that I looked into), and I can obviously not speak to nursing school at all, but I doubt seriously that the two are even roughly equivalent. Not in a pretentious-sounding way, just in a factual "they are very different" kind of way. Agreed. It's difficult to compare the two because they are oriented differently.


But on the other hand, there is a subset that is going to take that knowledge and then try to turn that around and use it against the teacher. So I fully understand the sentiment that is expressed on the board. What is using knowledge against the teacher?

Consider if a SRNA is taught by physicians, as many are. If the SRNA, highly competent because of their training by physicians, works in a collaborative practice instead of a supervisory practice, are they using the physician's knowledge against the physician?

Thus, is it possible to simultaneously benefit patients and work against certain national political physician interests?

I suppose it is (thoughtfully) :). What do you think?

I realize I've brought up the dreaded political issues, but I assure you, there is no ill will if you support ACT practice.

[JadamR15]

BTW,

"MDA" started as an insurance term.

Summit,

Clearly AnesRes's training is different. That misses the point. They (MDAs) probably feel it appears as "less" than their fellow MDs.

Personally, folks should be called what they like. I don't use the term if someone doesn't like it. And, I hate the insurance industry :).

[AnesRes2014]

What made you decide to go into anesthesia?

What type of practice are you looking to work in when you are an attending: ACT, MD only; PP, academia?

I can somewhat appreciate why you dislike the term MDA, but do you truly feel that it's use is meant to be derogatory? Perhaps it's just shorthand as others have said.

Last question, do you really feel that all those studies claiming CRNA solo safety, the opt out MM study, and the new IOm report have no merit at all? I'm not asking if you fully agree with them, but do you really think they are just coming out of left field with nonsense?

ETA: oh and Welcome! I look forward to a long standing collegial relationship!

Genetics? My grandfather was an OR tech, and my father is an OR nurse, so maybe I was destined to be in the OR?

Seriously, though, I don't think my reasons are that much different than most people's. Monitoring/manipulating physiology in real-time is incredibly interesting, and I love the technical/hands-on aspects of the field. Growing up in team sports, I love the teamwork aspect of the OR environment. And another aspect that I didn't fully appreciate until starting intern year is that I much prefer taking care of a smaller number of more acute patients than I do a floor of 30-something less-acute patients.

I think whether or not any term/word/phrase is derogatory is dependent on the user's intent. I'm sure the vast majority of users mean no ill-will by it. My opposition to it is more on the basis of inaccuracy; it's not the correct title. I'm sure it's a cultural thing; there is a lot of variation in educational requirements for nursing: LPN vs NA vs RN vs BSN vs MSN vs NP vs CRNA, and the distinctions have meaning. However, in medicine, aside from MD vs DO, there isn't really that same kind of distinction.

As for the great study debate, I will do my best to stay out of it as there are far more informed posters on both sides of the issue than I :) I will quote my favorite author (Michael Crichton) in saying that "Everyone has an agenda; except me." And I fully acknowledge medicine's history as a field with decades of dubious "studies."

[AnesRes2014]

Welcome, AnesRes.

But.... I believe your training IS different, right? (referring to above in bold)

I agree with others, that it's just a qualifier, and not a derogatory term. I believe "those" MDs are called other names ;)

Not really. You don't "specialize," so to speak, until residency. You do have some elective time 4th year of medical school (MS4) that you can tailor to whatever field you are interested in, but even that year there are standardized requirements.

This actually leads to probably fewer anesthesia applicants than there would otherwise be, as anesthesia is not typically a required rotation and often is done as an elective in 4th year, when you are already starting to apply for residency. For instance, I went to a state school with a strong emphasis on primary care. We had about a week of exposure to anesthesia during our 3rd year, which was recently axed. I can't say for sure, but I think it might have had something to do with a higher than average number of anesthesia applicants. My guess is that the thinking was, "less exposure to anesthesia = less people going IN to anesthesia" :)

[JadamR15]

Genetics? My grandfather was an OR tech, and my father is an OR nurse, so maybe I was destined to be in the OR?

Seriously, though, I don't think my reasons are that much different than most people's. Monitoring/manipulating physiology in real-time is incredibly interesting, and I love the technical/hands-on aspects of the field. Growing up in team sports, I love the teamwork aspect of the OR environment. And another aspect that I didn't fully appreciate until starting intern year is that I much prefer taking care of a smaller number of more acute patients than I do a floor of 30-something less-acute patients.

I think whether or not any term/word/phrase is derogatory is dependent on the user's intent. I'm sure the vast majority of users mean no ill-will by it. My opposition to it is more on the basis of inaccuracy; it's not the correct title. I'm sure it's a cultural thing; there is a lot of variation in educational requirements for nursing: LPN vs NA vs RN vs BSN vs MSN vs NP vs CRNA, and the distinctions have meaning. However, in medicine, aside from MD vs DO, there isn't really that same kind of distinction.

As for the great study debate, I will do my best to stay out of it as there are far more informed posters on both sides of the issue than I :) I will quote my favorite author (Michael Crichton) in saying that "Everyone has an agenda; except me." And I fully acknowledge medicine's history as a field with decades of dubious "studies."


A realist! :)

[AnesRes2014]

AnesRes,

Hey, welcome!

To help prevent degeneration of the thread:

You should know that some of us are OK conversing with you, despite the likelihood that you disagree with many CRNA/SRNAs regarding those professional issues that have divided our professions so deeply, and for so long. I'm sure we are both familiar with the carefully worded arguments from both sides, so reviewing thoughtlessly them would be a moot point. Thankfully, agreement is not a necessity for learning or for dialogue.


Agreed. It's difficult to compare the two because they are oriented differently.

What is using knowledge against the teacher?

Consider if a SRNA is taught by physicians, as many are. If the SRNA, highly competent because of their training by physicians, works in a collaborative practice instead of a supervisory practice, are they using the physician's knowledge against the physician?

Thus, is it possible to simultaneously benefit patients and work against certain national political physician interests?

I suppose it is (thoughtfully) :). What do you think?

I realize I've brought up the dreaded political issues, but I assure you, there is no ill will if you support ACT practice.

I would define using knowledge against the teacher as, "thanks for teaching me this, now I am going to take your job." I'm pretty sure no one in any line of work is going to be in support of that kind of development. That is a pretty strong disincentive. Therefore, I can't really be in support of CRNA-only groups replacing MD-only or ACT-model groups for jobs. In areas of the country where patient care would suffer otherwise, sure. But delivery of health care (especially with recent changes in health care policy) is a medicine-wide issue (particularly family medicine/primary care) that is better left for another thread.

[JadamR15]

I would define using knowledge against the teacher as, "thanks for teaching me this, now I am going to take your job." I'm pretty sure no one in any line of work is going to be in support of that kind of development. That is a pretty strong disincentive. Therefore, I can't really be in support of CRNA-only groups replacing MD-only or ACT-model groups for jobs. In areas of the country where patient care would suffer otherwise, sure. But delivery of health care (especially with recent changes in health care policy) is a medicine-wide issue (particularly family medicine/primary care) that is better left for another thread.


Smart, too. :). Good answer.

[JadamR15]

In regards to medical training, would you say that medical school is "uniform," more or less? That is, most students learn the same thing, at the same progression?

Generally speaking, not considering research interests or experience, etc.

[Skeebum]

However, in medicine, aside from MD vs DO, there isn't really that same kind of distinction.

It’s funny you should mention this.

Honestly, just last night, I was at work and one of the PACU nurses I work with asked what DO meant. After telling her, I asked why she asked. She pointed to a list of all the anesthesia providers, and the Doc I was working with was listed as Jane Doe DO. I’ve worked with this gal for over a year and never realized she was DO, and don’t really care now that I do know.

I have worked with some DOs who, IMO, really felt a need to assert themselves. It was almost as if they were trying to prove something.

I’m not saying this is true for all DOs, just something I’ve noticed in a few.

As an MD………..do you guys make a distinction on a practice level? They take the same boards? Don’t they?

[ETA--------now that I know she is a DO --------- I'll probably have to have some fun with the DOA thing :) ]

[AnesRes2014]

In regards to medical training, would you say that medical school is "uniform," more or less? That is, most students learn the same thing, at the same progression?

Generally speaking, not considering research interests or experience, etc.

Most definitely. The first 2 years are generally spent in the classroom, though a significant number of schools are incorporating some degree of clinical experience/exposure in the pre-clinical years now. The second 2 years, everyone in the country will rotate through internal medicine, family medicine, surgery, pediatrics, OB/GYN, psychiatry. Some of the more fringe-y specialties are variable, for example my school has a neurology rotation, my wife's didn't.

[AnesRes2014]

It’s funny you should mention this.

Honestly, just last night, I was at work and one of the PACU nurses I work with asked what DO meant. After telling her, I asked why she asked. She pointed to a list of all the anesthesia providers, and the Doc I was working with was listed as Jane Doe DO. I’ve worked with this gal for over a year and never realized she was DO, and don’t really care now that I do know.

I have worked with some DOs who, IMO, really felt a need to assert themselves. It was almost as if they were trying to prove something.

I’m not saying this is true for all DOs, just something I’ve noticed in a few.

As an MD………..do you guys make a distinction on a practice level? They take the same boards? Don’t they?

Nice quote in your sig, by the way.

Once you're done with medical school, everyone will take Step 3 of the USMLE (US Medical Licensing Exam) at some point during residency, which is standardized for all MDs. Once that hurdle is passed, and you have completed residency, board certifications are specialty-dependent. There is occasional overlap by individuals that might complete multiple residencies; for instance, there seem to be a fair number of anesthesiologists that are double-boarded in internal medicine and anesthesiology. Or even triple-boarded in internal medicine, crticial care, and anesthesiology. My understanding is that you don't necessarily have to be board-certified to be gainfully employed somewhere, but it sure makes life easier.

[JadamR15]

Are not DO's required to take the COMLEX prior to/in addition to the USMLEs?

I've read the DO vs MD thing is all but dead except in a few, slow-to-adopt ivory towers. True?

[MmacFN]

Anesres

Every post you make only causes me to like you more.

Glad yer here.

[AnesRes2014]

Are not DO's required to take the COMLEX prior to/in addition to the USMLEs?

I've read the DO vs MD thing is all but dead except in a few, slow-to-adopt ivory towers. True?

Haha, depends on who you ask. I think it's pretty much dead, because my med school's residency program/faculty had a number of DOs who were all fantastic, and the curriculum is more or less the same (they have some osteopathic courses we don't have). DO's don't have to take the USMLEs, though if they are applying for an MD residency it is almost a requirement, as it's the best way to standardize their knowledge base vs MDs.

That said, and I know I would take flak for it from some DOs, but in general applicants to DO schools are less competitive than those to MD schools. How they come out the other side, of course, is solely dependent on how much effort they put into it. Same for the MD degree in that regard.

[ya herd]

I'll chime in as well. I am a CA-1 (PGY-2) that is roughly 6 months into my anesthesia training. I have an immediate family member that is a CRNA (private practice). I will try to express myself without being inflammatory. There is obviously a lot of stuff that I disagree with on this board, however I do think that there is a place for the ACT model.

I tend to agree with AnesRes sentiments. Our training is different. From my experience, my intern year taught me how to deal with most issues a doctor would face on the floors. Recognizing SICK from non-SICK, and knowing how to deal with them accordingly. As an intern in the ICU, you learn which nurses "get it" and which ones don't really quickly. As I'm sure the nurses learn the same about the interns. I'm sure a lot of generalizations are made by both sides when they witness the other side flounder or do something ridiculous.

That being said, I was a bit offended when I read on a different thread that as interns we learn what nurses already know. Just by talking with my immediate family member (who was an ICU nurse for 2 years before becoming a CRNA) I know that this is NOT true. Also, years in the ICU does not necessarily equate with knowledge in medicine. How many times did I admit numerous patients to the ICU while a lot of the ICU nurses sat around on computers during the night. Don't get me wrong, settling in a patient into the ICU takes a crazy amount of work which I respect. But that work is different from admitting and writing orders, getting pimped by upper level residents/attendings about management, and then having to round the next day and get pimped more - long after the night-shift nurses are home sleeping. I rarely would see a nurse trying to further his/her education while in the ICU unless they were studying for the GRE to become a mid-level practitioner (and most of the time this was studying GRE books, not medicine).

The things that nurses do have an edge on are the every day skills of an anesthesia provider. Setting up pumps/drips, administering medications, starting IVs, and many of the other technical skills that most interns don't do much of (especially at large academic institutions). I think that sometimes interns and early CA-1s show a LACK of these skills, and it is assumed that this is a LACK of knowledge. This is just being in a new role, which would take anyone time to adjust to. No one comes out of the womb knowing how to start an IV or set up an epinephrine drip.

Taking the knowledge we get as medical students and the training we get as anesthesiology residents, I believe that we are trained to diagnose and treat any issues that might be presented to us in the clinical setting. The background knowledge we have provides a broad foundation to consider all aspects when caring for the patient. I honestly believe that nursing school and ICU experience do NOT provide this. As a simple reference, I cringed when I read something about solution tonicity having to do with pH on this board. These are two concepts I would hope that anyone practicing in anesthesia would have down cold. These are the things that are hammered into us during our medical training.

As far as the studies proving equivalent outcomes, I believe that we are fortunate to provide anesthesia in a time when it is very safe. Especially safe for healthy ASA-1/2s having non-complicated procedures. I believe that this is mostly what is done in rural areas where CRNAs practice independently, and I believe that this was what was studied. Am I OK with independent CRNA practice? Absolutely NOT, but I have witnessed it occurring. Just as I have scrubbed in with a rural family medicine physician performing a c-section. There is a NEED for rural healthcare, and MDs in general have shot ourselves in the foot by not wanting to practice in rural areas. I think that there is a gap in logic when one tries to generalize the outcomes to these studies to other patient populations. The funding of these studies is a bit suspect as well, as we have often seen different outcomes to studies based on who/where the research is done (beta blockade for CHF, etc.).

I have discussed a lot of this with my immediate family member who is a CRNA, who agrees with pretty much all that I have said. This family member does not wish to practice independently, nor do any of his/her colleagues in the group. Just from this, I would assume that most CRNAs are not interested in independent practice. After all, my family member makes roughly $120k yearly working a flexible 36 hours per week. Hardly anything to complain about.

Lastly, I feel like the term MDA tries to blur the line between CRNA and MD. Whether it is an insurance term or not, I feel that it is often used just to get on our nerves. Which, if that is the intention, solid work. :) MD would be just fine, just as it is for the rest of my medical school class, regardless of specialty.

Alright...enough of my rambling. I'm sure that my opinions have made some blood boil, but I'm just trying to give our (anesthesiology residents) perspective. I have tried not to say anything ban-worthy, but if I do get banned, I will not post again. I'm not one to be an unwelcome houseguest.

Starting arguments is not my intention but defending my choice of career is something I will stand by.

[JadamR15]

Wow...look at all the folks lurking on this thread...jeez.

Ya Herd...hey, welcome to you too. :).

You make some good points, and I'm sure some are ready to jump down your throat. Clearly, those folks at SDN would jump down the throats of those here as well! :)

Seriously though, besides the obvious disagreements between our two groups and the arguments (which do get old)...if I were you, I'd be defending my career choice as well, Cheers :).

The idea of a 'care team' isn't so bad - it's just what the ASA made it to be. Specifically, the 1972 original statement that basically regulated CRNAs to a general anesthesia technician, who would need to yell every time any abnormality occurred. I've spoken with many CRNAs who enjoy the team environment, but NONE who enjoy being micromanaged or having their knowledge diminished. Unfortunantly, it happens. So the wars continue... *sigh*


Truthfully, many providers (nurse and physician) see collaborative practices as the future. There are many, many reasons for this. Some are based on the professions: CRNAs are capable of regional anesthesia, don't you think? Well, if you adhere to the ACT, you shouldn't think so. Others are financial (ACTs are expensive, especially for ASA 1s and 2s).

A lot of this had to do with basic tenets of professions (ie, should a profession be responsible for regulating another profession, and if so, is the latter actually a profession in the purest sense?) Not to mention power, influence, money, control, etc. Bla bla bla, you know the drill.

I could go on about various aspects of the "special" relationship between our two groups...but that would be forever long. One thing's for sure, I don't hate on people for defending their turf or paycheck. Lord knows I do :).

[Esper]

Thank you for your answers. Very enlightening and respectful. Hopefully all of our users will respond the same in return.


Genetics? My grandfather was an OR tech, and my father is an OR nurse, so maybe I was destined to be in the OR?

Seriously, though, I don't think my reasons are that much different than most people's. Monitoring/manipulating physiology in real-time is incredibly interesting, and I love the technical/hands-on aspects of the field. Growing up in team sports, I love the teamwork aspect of the OR environment. And another aspect that I didn't fully appreciate until starting intern year is that I much prefer taking care of a smaller number of more acute patients than I do a floor of 30-something less-acute patients.

I think whether or not any term/word/phrase is derogatory is dependent on the user's intent. I'm sure the vast majority of users mean no ill-will by it. My opposition to it is more on the basis of inaccuracy; it's not the correct title. I'm sure it's a cultural thing; there is a lot of variation in educational requirements for nursing: LPN vs NA vs RN vs BSN vs MSN vs NP vs CRNA, and the distinctions have meaning. However, in medicine, aside from MD vs DO, there isn't really that same kind of distinction.

As for the great study debate, I will do my best to stay out of it as there are far more informed posters on both sides of the issue than I :) I will quote my favorite author (Michael Crichton) in saying that "Everyone has an agenda; except me." And I fully acknowledge medicine's history as a field with decades of dubious "studies."

[Summitk2]

Welcome, ya herd!

You're certainly entitled to your opinions, but I personally don't see a reason to "defend" your career on a CRNA forum. Nurse-anesthesia providers have reasons for choosing their paths, and we know docs have reasons for choosing theirs. We're not going to see eye-to-eye on anesthesia politics, so let's not waste our time trying to resolve anything--it's pointless in my mind. I think we can agree to disagree without actually having an argument.... it's all been said before.

I think what's valuable, and what AnesRes came to do, is have some healthy dialogue regarding our different backgrounds. This ends very quickly when labels start being placed on the other side. I'm afraid your comments changed the tone of this tempered conversation, and I'm hoping a feeding frenzy doesn't ensue! I could write pages in response to your post, but seriously what would be the point? :D

Thanks, BTW, on the MD(A) clarification. I've never considered it to be anything like "CRNA," and also had no idea it was an insurance term. Glad I didn't say that to anyone's face before getting the background.

[Anthony]

Welcome and thanks for the post.


I'll chime in as well. I am a CA-1 (PGY-2) that is roughly 6 months into my anesthesia training. I have an immediate family member that is a CRNA (private practice). I will try to express myself without being inflammatory. There is obviously a lot of stuff that I disagree with on this board, however I do think that there is a place for the ACT model.

I tend to agree with AnesRes sentiments. Our training is different. From my experience, my intern year taught me how to deal with most issues a doctor would face on the floors. Recognizing SICK from non-SICK, and knowing how to deal with them accordingly. As an intern in the ICU, you learn which nurses "get it" and which ones don't really quickly. As I'm sure the nurses learn the same about the interns. I'm sure a lot of generalizations are made by both sides when they witness the other side flounder or do something ridiculous.

That being said, I was a bit offended when I read on a different thread that as interns we learn what nurses already know. Just by talking with my immediate family member (who was an ICU nurse for 2 years before becoming a CRNA) I know that this is NOT true. Also, years in the ICU does not necessarily equate with knowledge in medicine. How many times did I admit numerous patients to the ICU while a lot of the ICU nurses sat around on computers during the night. Don't get me wrong, settling in a patient into the ICU takes a crazy amount of work which I respect. But that work is different from admitting and writing orders, getting pimped by upper level residents/attendings about management, and then having to round the next day and get pimped more - long after the night-shift nurses are home sleeping. I rarely would see a nurse trying to further his/her education while in the ICU unless they were studying for the GRE to become a mid-level practitioner (and most of the time this was studying GRE books, not medicine).

The things that nurses do have an edge on are the every day skills of an anesthesia provider. Setting up pumps/drips, administering medications, starting IVs, and many of the other technical skills that most interns don't do much of (especially at large academic institutions). I think that sometimes interns and early CA-1s show a LACK of these skills, and it is assumed that this is a LACK of knowledge. This is just being in a new role, which would take anyone time to adjust to. No one comes out of the womb knowing how to start an IV or set up an epinephrine drip.

Taking the knowledge we get as medical students and the training we get as anesthesiology residents, I believe that we are trained to diagnose and treat any issues that might be presented to us in the clinical setting. The background knowledge we have provides a broad foundation to consider all aspects when caring for the patient. I honestly believe that nursing school and ICU experience do NOT provide this. As a simple reference, I cringed when I read something about solution tonicity having to do with pH on this board. These are two concepts I would hope that anyone practicing in anesthesia would have down cold. These are the things that are hammered into us during our medical training.

As far as the studies proving equivalent outcomes, I believe that we are fortunate to provide anesthesia in a time when it is very safe. Especially safe for healthy ASA-1/2s having non-complicated procedures. I believe that this is mostly what is done in rural areas where CRNAs practice independently, and I believe that this was what was studied. Am I OK with independent CRNA practice? Absolutely NOT, but I have witnessed it occurring. Just as I have scrubbed in with a rural family medicine physician performing a c-section. There is a NEED for rural healthcare, and MDs in general have shot ourselves in the foot by not wanting to practice in rural areas. I think that there is a gap in logic when one tries to generalize the outcomes to these studies to other patient populations. The funding of these studies is a bit suspect as well, as we have often seen different outcomes to studies based on who/where the research is done (beta blockade for CHF, etc.).

I have discussed a lot of this with my immediate family member who is a CRNA, who agrees with pretty much all that I have said. This family member does not wish to practice independently, nor do any of his/her colleagues in the group. Just from this, I would assume that most CRNAs are not interested in independent practice. After all, my family member makes roughly $120k yearly working a flexible 36 hours per week. Hardly anything to complain about.

Lastly, I feel like the term MDA tries to blur the line between CRNA and MD. Whether it is an insurance term or not, I feel that it is often used just to get on our nerves. Which, if that is the intention, solid work. :) MD would be just fine, just as it is for the rest of my medical school class, regardless of specialty.

Alright...enough of my rambling. I'm sure that my opinions have made some blood boil, but I'm just trying to give our (anesthesiology residents) perspective. I have tried not to say anything ban-worthy, but if I do get banned, I will not post again. I'm not one to be an unwelcome houseguest.

Starting arguments is not my intention but defending my choice of career is something I will stand by.

[AnesRes2014]

Welcome, ya herd!

You're certainly entitled to your opinions, but I personally don't see a reason to "defend" your career on a CRNA forum. Nurse-anesthesia providers have reasons for choosing their paths, and we know docs have reasons for choosing theirs. We're not going to see eye-to-eye on anesthesia politics, so let's not waste our time trying to resolve anything--it's pointless in my mind. I think we can agree to disagree without actually having an argument.... it's all been said before.

I think what's valuable, and what AnesRes came to do, is have some healthy dialogue regarding our different backgrounds. This ends very quickly when labels start being placed on the other side. I'm afraid your comments changed the tone of this tempered conversation, and I'm hoping a feeding frenzy doesn't ensue! I could write pages in response to your post, but seriously what would be the point? :D

Thanks, BTW, on the MD(A) clarification. I've never considered it to be anything like "CRNA," and also had no idea it was an insurance term. Glad I didn't say that to anyone's face before getting the background.

Couldn't agree more.

In the interest of redirecting this thread back on track, I'll clear up a few patient-care/workload questions that have come up in my time on the hospital.

1) Work-hour regulations for residents are 80hrs averaged over a 4wk time period. So yes, I can work 100 hours in an 8-day period and not break any rules. Shifts are capped at 30 hours (24 of patient care, 6 hours of administrative duties). So, while there is no excuse for a resident being disrespectful or demeaning, if someone is a little short or snippy, that is not necessarily who they are in a different setting.

2) There is often times no limit to the number of patients we are responsible for. On my surgery rotation, it ranged from 15-30. There were times that I just didn't have time to see patients more than the one time we saw them on team rounds, due to assisting in the OR, admitting patients directly or through the ED, discharging patients, seeing consults, etc. It hurts me as a physician to have so little patient contact, and I swore to myself as a med student that it wouldn't be that way, but really, there's no choice.

In those cases, a good nurse is invaluable in managing/triaging patients for me. Dealing with all the drip titrations, pain med requests, answering patient questions, keeping me up to date on changes in the patient's condition, all help me in turn triage who is SICK vs NON-SICK and where to focus my time. The worst days are when you have multiple nurses working that play terrible defense, and you're being hammer-paged by tylenol orders and patients wanting to sit and chat for 30 minutes about this rash they had this one time. On the flip side, an overly assertive nurse can cause just as many problems if they don't communicate.

My experience thus far is that this is less common with ICU nurses, and they as a whole are more competent/independent.

[Esper]

While I disagree with some of what you say, I think you did it in a very respectful tone.

I just want to comment on two things, as I have a very busy day and I need to stop procrastinating.

I agree that interns training is different than an ICU nurse experience. I'm not under the impression that an intern is learning was an ICU nurse already knows because I feel they are learning different things. Writing orders, getting pimped, etc is a much different experience. I agree that a ICU nurse is also learning many technical skills that interns tend to miss out on because they are too busy writing orders and getting pimped. However, I think that you are forgetting other experiences that an ICU nurse are getting. Many times the ICU nurse is taking care of a sick one on one patient, doing nothing but staring at monitors and the patient, recognizing those PVCs are a result of low K+, that heart rate jump is probably the result of a rebleed, that drop in BP is from too much propofol, the K+ cannot be correct until the Mg++ is, recognizing that the ventilator settings need to be changed (and how I should adjust them) according to blood gases. We are sitting there and listening to everything going on in that room for hours, just as in the OR. It really helps beef up those assessment skills, recognizing a change, and what that change is.

Also, at least on night shift with my unit, I was given a great deal of freedom to send down labs or draw an ABG without calling the resident if I thought some value was going to be off, as well as freedom in other areas.

I'm not saying ICU nursing is better, just different and that there are some areas that we get good experience with that you may not think about.

I'll chime in as well. I am a CA-1 (PGY-2) that is roughly 6 months into my anesthesia training. I have an immediate family member that is a CRNA (private practice). I will try to express myself without being inflammatory. There is obviously a lot of stuff that I disagree with on this board, however I do think that there is a place for the ACT model.

I tend to agree with AnesRes sentiments. Our training is different. From my experience, my intern year taught me how to deal with most issues a doctor would face on the floors. Recognizing SICK from non-SICK, and knowing how to deal with them accordingly. As an intern in the ICU, you learn which nurses "get it" and which ones don't really quickly. As I'm sure the nurses learn the same about the interns. I'm sure a lot of generalizations are made by both sides when they witness the other side flounder or do something ridiculous.

That being said, I was a bit offended when I read on a different thread that as interns we learn what nurses already know. Just by talking with my immediate family member (who was an ICU nurse for 2 years before becoming a CRNA) I know that this is NOT true. Also, years in the ICU does not necessarily equate with knowledge in medicine. How many times did I admit numerous patients to the ICU while a lot of the ICU nurses sat around on computers during the night. Don't get me wrong, settling in a patient into the ICU takes a crazy amount of work which I respect. But that work is different from admitting and writing orders, getting pimped by upper level residents/attendings about management, and then having to round the next day and get pimped more - long after the night-shift nurses are home sleeping. I rarely would see a nurse trying to further his/her education while in the ICU unless they were studying for the GRE to become a mid-level practitioner (and most of the time this was studying GRE books, not medicine).

The things that nurses do have an edge on are the every day skills of an anesthesia provider. Setting up pumps/drips, administering medications, starting IVs, and many of the other technical skills that most interns don't do much of (especially at large academic institutions). I think that sometimes interns and early CA-1s show a LACK of these skills, and it is assumed that this is a LACK of knowledge. This is just being in a new role, which would take anyone time to adjust to. No one comes out of the womb knowing how to start an IV or set up an epinephrine drip.

Taking the knowledge we get as medical students and the training we get as anesthesiology residents, I believe that we are trained to diagnose and treat any issues that might be presented to us in the clinical setting. The background knowledge we have provides a broad foundation to consider all aspects when caring for the patient. I honestly believe that nursing school and ICU experience do NOT provide this. As a simple reference, I cringed when I read something about solution tonicity having to do with pH on this board. These are two concepts I would hope that anyone practicing in anesthesia would have down cold. These are the things that are hammered into us during our medical training.

As far as the studies proving equivalent outcomes, I believe that we are fortunate to provide anesthesia in a time when it is very safe. Especially safe for healthy ASA-1/2s having non-complicated procedures. I believe that this is mostly what is done in rural areas where CRNAs practice independently, and I believe that this was what was studied. Am I OK with independent CRNA practice? Absolutely NOT, but I have witnessed it occurring. Just as I have scrubbed in with a rural family medicine physician performing a c-section. There is a NEED for rural healthcare, and MDs in general have shot ourselves in the foot by not wanting to practice in rural areas. I think that there is a gap in logic when one tries to generalize the outcomes to these studies to other patient populations. The funding of these studies is a bit suspect as well, as we have often seen different outcomes to studies based on who/where the research is done (beta blockade for CHF, etc.).

I have discussed a lot of this with my immediate family member who is a CRNA, who agrees with pretty much all that I have said. This family member does not wish to practice independently, nor do any of his/her colleagues in the group. Just from this, I would assume that most CRNAs are not interested in independent practice. After all, my family member makes roughly $120k yearly working a flexible 36 hours per week. Hardly anything to complain about.

Lastly, I feel like the term MDA tries to blur the line between CRNA and MD. Whether it is an insurance term or not, I feel that it is often used just to get on our nerves. Which, if that is the intention, solid work. :) MD would be just fine, just as it is for the rest of my medical school class, regardless of specialty.

Alright...enough of my rambling. I'm sure that my opinions have made some blood boil, but I'm just trying to give our (anesthesiology residents) perspective. I have tried not to say anything ban-worthy, but if I do get banned, I will not post again. I'm not one to be an unwelcome houseguest.

Starting arguments is not my intention but defending my choice of career is something I will stand by.

[maliggs]

Couldn't agree more.

In the interest of redirecting this thread back on track, I'll clear up a few patient-care/workload questions that have come up in my time on the hospital.

1) Work-hour regulations for residents are 80hrs averaged over a 4wk time period. So yes, I can work 100 hours in an 8-day period and not break any rules. Shifts are capped at 30 hours (24 of patient care, 6 hours of administrative duties). So, while there is no excuse for a resident being disrespectful or demeaning, if someone is a little short or snippy, that is not necessarily who they are in a different setting.

2) There is often times no limit to the number of patients we are responsible for. On my surgery rotation, it ranged from 15-30. There were times that I just didn't have time to see patients more than the one time we saw them on team rounds, due to assisting in the OR, admitting patients directly or through the ED, discharging patients, seeing consults, etc. It hurts me as a physician to have so little patient contact, and I swore to myself as a med student that it wouldn't be that way, but really, there's no choice.

In those cases, a good nurse is invaluable in managing/triaging patients for me. Dealing with all the drip titrations, pain med requests, answering patient questions, keeping me up to date on changes in the patient's condition, all help me in turn triage who is SICK vs NON-SICK and where to focus my time. The worst days are when you have multiple nurses working that play terrible defense, and you're being hammer-paged by tylenol orders and patients wanting to sit and chat for 30 minutes about this rash they had this one time. On the flip side, an overly assertive nurse can cause just as many problems if they don't communicate.

My experience thus far is that this is less common with ICU nurses, and they as a whole are more competent/independent.

LMAO! I sympathize with you. That would really suck. In all honesty, where I am doing my training now is a VERY good environment, there is very little animocity between MDs and CRNAs. Actually I would say there is none. I realize it is not like this everywhere, as I have many friends that have gone to other schools and received a completely different attitude during school. I guess I have really never been exposed to the harsh reality that exists at other hospitals. Where I worked in the SICU, one of my recommendations was from an MD (trying not to use the MDA term anymore...heehee!) and it was a great working environment there as well.

I agree that there are differences across the board: differences in ICU nurses willingness to learn/be a team player, differences in YOUR training depending on your attending, etc, differences in CRNA schools/training.

Welcome to the forum.

[Anesthesiologist]

I would venture to say (and I can only speak from MY experience) that a first year intern has NO WHERE CLOSE to the same experience as an RN working in a high acuity ICU.

I agree with this, although perhaps in a different sense than you had intended. Interns do rely a lot on team members, especially intelligent, experienced ICU nurses! Let me give a little perspective on this:

Internship is the most trying year of a physician-in-training. An MD comes fresh out of medical school with a vast knowledge base, but rather limited experience on how to apply it to the bedside. This young, inexperienced physician is now asked to work tremendous hours (36-hour shifts, 80-100 hour work weeks). The exhaustion is tremendous. To add insult to injury, just as he begins to master an environment and a patient population in one care area, in just a month's time he is asked to move to a new care area and relearn things from scratch. (More on this below).

As such, the smart intern has no choice but rely on the experience of other, more experienced team members to guide him through this year. I remember seeking out the most experienced ICU nurses and soliciting their advice. It is the stupid intern that tries to do it without help.

That said, I do not think you can leap to the conclusion that ICU nurses are superior to interns. It is an apples-to-oranges comparison. Here are some of the reasons:

1) The intern is learning for the first time to make independent medical decisions. No matter how senior, skilled, or knowledgeable the ICU nurse is, the nurse is NOT there to make high-level management decisions. The ICU attending is making those decisions and managing the overall care.

2) The ICU nurse works in ONE care area: the ICU. The intern has to come up to speed on how things are done in one area, and then must start over in a new area the next month. Interns rotate through a number of different areas, depending on the type of internship. I did ICU, pediatrics, surgery, obstetrics, medicine, cardiology, etc. On each of those units, I became that doctor (e.g., on OB I evaluated pregnant women and delivered 50+ babies, on cardiology I did consults on cardiac issues and interpreted complex EKGs, on surgery, I operated). The nurses on each unit knew more than me about their respective areas -- at least in a logistical sense. Overall, I had a knowledge base that exceeded any given nurse. Take a nurse from the ICU and put her on OB, she would be clueless, but I as the intern would be functional (even if marginally so) in each of those environments. The broad training helps interns to develop an integrated, comprehensive view of medicine.

3) Comparing an intern to a seasoned ICU nurse is like comparing a West Point cadet to a Master Chief officer. You need to compare the general to the master chief officer. Or, you can compare the West Point cadet to the boot camp trainee for enlisted soldiers. In my ICU experience, I came across some fantastic, intelligent, experienced ICU nurses. The new ones (i.e., the freshly minted, fully qualified RNs) were often more clueless than interns (i.e, physicians at the beginning of their real clinical training).

I view the breakdown of physician education like this:
1) University: here you become educated in the general sense, you develop critical thinking skills, and an educated lens through which to view the world. You also learn the fundamentals of science that will be required in medical school.

2) Medical school (first 2 years): This is like a big vocabulary lesson. You learn the words and basic concepts of medicine, but you are useless in a clinical environment.

3) Medical school (clinical years): This is a 2-year long orientation to the clinical environment in different areas of medicine. You will begin to develop a process for diagnoses and treatment, but you are still generally useless in a clinical environment.

4) Intership: where the rubber meets the road. It is a trial-by-fire that cannot be understood by someone who has not gone through it. It is here that you slowly develop the thought process of a real physician. By the end, you may not have the specific knowledge or skills to solve a problem, but you know how you will stabilize the patient and get the resources that the patient needs.

5) Residency: this is the in-depth specialty training
6) Fellowship: for the development of deep expertise in a subspecialty of your field.

Now you might argue that all of this well-roundedness is irrelevant to the OR. And I would disagree with you.

If I am taking care of a patient with CHF, I can get the patient out of the OR alive just as well as you can. But I am tailoring my anesthetic with considerations to the treatment plan of medicine team that will be taking care of him post-op, because once upon a time, I was on that team. I will understand his preop meds, because I was once in the position of prescribing them.

If I am taking care of a patient with end-stage COPD, I similarly will tailor my anesthetic not just to get the patient out of the OR alive, but to dove-tail into the treatment plan of the pulmonologist -- because I was once on the medicine team that took care of that patient on the ward.

That is a how I see things. I do not mean to sound demeaning at all, so please forgive me if I come across that way. I welcome your questions.

[Esper]

I agree that you make a valid point of how you can transition a patient into another physician's care. Do you think this holds up over time? I'm not saying it ever completely goes away, but I would think this ability could diminish over time and those rotations become a distant memory. Certainly as treatment evolves it could diminsh as you cannot keep up to date on every specialty.

I believe this because I once asked a cardiologist friend of mine for advice on treating some disorder (I forget what now) and his response was "if it's not between here and here (pointing to neck to epigastric), then you can assume I know little to nothing" we had a good laugh afterwards. I also asked a FP one time about beta microglobulin and he said "I haven't thought about that since medical school. All I know is it goes up in multiple myeoloma." he also went into a detailed explanation of if you don't use it everyday, you eventually forget it and that's why he has a wall of textbooks.

Or is being an intern so traumatic that it causes PTSD so you will always remember? I've known some sadistic attendings that might try that method.

[gwo_neg_la]

The things that nurses do have an edge on are the every day skills of an anesthesia provider. Setting up pumps/drips, administering medications, starting IVs, and many of the other technical skills that most interns don't do much of (especially at large academic institutions).

I would argue that ICU RN's not only have an upper hand in "setting up" epinephrine drips, but also in managing patients on them. The finer points of managing vasopressors, ionotropes, and chronotropes can be a tricky skill to master during anesthesia training and ICU nurses do it every day. i.e. A patient in end stage heart failure with epi, levophed, and dopamine running and the RN has orders to "titrate to map > 60". Titrating those drips is NOT low level decision making. It involves an understanding of cardiac physiology and advanced hemodynamics. Anyway, I do believe that an ICU RN from a good unit has excellent experience in understanding and applying these concepts long before they enter anesthesia school. And one with a few years of good ICU experience probably will more vasoprssor drips (other than neo of course) that you will during your residency. (depending on how heavy your heart rotation is)

In any case, I appreciate your respectful postings and desire for open dialogue.

[maliggs]

I agree with this, although perhaps in a different sense than you had intended. Interns do rely a lot on team members, especially intelligent, experienced ICU nurses! Let me give a little perspective on this:

Internship is the most trying year of a physician-in-training. An MD comes fresh out of medical school with a vast knowledge base, but rather limited experience on how to apply it to the bedside. This young, inexperienced physician is now asked to work tremendous hours (36-hour shifts, 80-100 hour work weeks). The exhaustion is tremendous. To add insult to injury, just as he begins to master an environment and a patient population in one care area, in just a month's time he is asked to move to a new care area and relearn things from scratch. (More on this below).

As such, the smart intern has no choice but rely on the experience of other, more experienced team members to guide him through this year. I remember seeking out the most experienced ICU nurses and soliciting their advice. It is the stupid intern that tries to do it without help.

That said, I do not think you can leap to the conclusion that ICU nurses are superior to interns. It is an apples-to-oranges comparison. Here are some of the reasons:

1) The intern is learning for the first time to make independent medical decisions. No matter how senior, skilled, or knowledgeable the ICU nurse is, the nurse is NOT there to make high-level management decisions. The ICU attending is making those decisions and managing the overall care.

2) The ICU nurse works in ONE care area: the ICU. The intern has to come up to speed on how things are done in one area, and then must start over in a new area the next month. Interns rotate through a number of different areas, depending on the type of internship. I did ICU, pediatrics, surgery, obstetrics, medicine, cardiology, etc. On each of those units, I became that doctor (e.g., on OB I evaluated pregnant women and delivered 50+ babies, on cardiology I did consults on cardiac issues and interpreted complex EKGs, on surgery, I operated). The nurses on each unit knew more than me about their respective areas -- at least in a logistical sense. Overall, I had a knowledge base that exceeded any given nurse. Take a nurse from the ICU and put her on OB, she would be clueless, but I as the intern would be functional (even if marginally so) in each of those environments. The broad training helps interns to develop an integrated, comprehensive view of medicine.

3) Comparing an intern to a seasoned ICU nurse is like comparing a West Point cadet to a Master Chief officer. You need to compare the general to the master chief officer. Or, you can compare the West Point cadet to the boot camp trainee for enlisted soldiers. In my ICU experience, I came across some fantastic, intelligent, experienced ICU nurses. The new ones (i.e., the freshly minted, fully qualified RNs) were often more clueless than interns (i.e, physicians at the beginning of their real clinical training).

I view the breakdown of physician education like this:
1) University: here you become educated in the general sense, you develop critical thinking skills, and an educated lens through which to view the world. You also learn the fundamentals of science that will be required in medical school.

2) Medical school (first 2 years): This is like a big vocabulary lesson. You learn the words and basic concepts of medicine, but you are useless in a clinical environment.

3) Medical school (clinical years): This is a 2-year long orientation to the clinical environment in different areas of medicine. You will begin to develop a process for diagnoses and treatment, but you are still generally useless in a clinical environment.

4) Intership: where the rubber meets the road. It is a trial-by-fire that cannot be understood by someone who has not gone through it. It is here that you slowly develop the thought process of a real physician. By the end, you may not have the specific knowledge or skills to solve a problem, but you know how you will stabilize the patient and get the resources that the patient needs.

5) Residency: this is the in-depth specialty training
6) Fellowship: for the development of deep expertise in a subspecialty of your field.

Now you might argue that all of this well-roundedness is irrelevant to the OR. And I would disagree with you.

If I am taking care of a patient with CHF, I can get the patient out of the OR alive just as well as you can. But I am tailoring my anesthetic with considerations to the treatment plan of medicine team that will be taking care of him post-op, because once upon a time, I was on that team. I will understand his preop meds, because I was once in the position of prescribing them.

If I am taking care of a patient with end-stage COPD, I similarly will tailor my anesthetic not just to get the patient out of the OR alive, but to dove-tail into the treatment plan of the pulmonologist -- because I was once on the medicine team that took care of that patient on the ward.

That is a how I see things. I do not mean to sound demeaning at all, so please forgive me if I come across that way. I welcome your questions.

I agree with most of what you say. I agree that you have a more rounded education. But I also think that if you don't use it, you lose it. Sure, I was able to do rotations in pediatrics and OB, and pass with flying colors. But once I became an ICU nurse, all of that went out the window. ICU is a VERY specialized field, especially SURGICAL ICU. However, being able to recognize/analyze when a patient is getting worse/better, managing vents, gtts, analyzing labs, etc are ALL skills that are relevant to anesthesia and the OR. It's not called SURGICAL ICU for nothing....most of those patients are going to/coming back from surgery. Hence, they are often the same patients (besides ASA 1/2) that we see in the OR. We see patients with CHF, COPD, liver/renal failure, etc every single day in the SICU. We manage hypertensive, septic, hypovolemic patients every day.

I guess what I don't understand is...how would your "tailoring" of a CHF patient anesthesia differ from mine? Because you got a little bit of knowledge in a lot of areas (OB, peds, cards, ICU, etc), and I have a little more knowledge in ONE area (ICU, which may come into play more acutely in the operating room), how does that help you giving anesthesia?

My aunt was a flight trauma surgeon for the army back in the day. Now she is the Director of Occ. Med at a hospital. She will be the first one to tell me that she remembers NOTHING but a distant memory when I talk to her about what I'm learning. I think that all that knowledge of random facts, diseases, etc may be useful at some point, but the reality of you remembering anything OTHER than what you use on a daily basis is slim to none.

[ethernaut]

...I do not think you can leap to the conclusion that ICU nurses are superior to interns. It is an apples-to-oranges comparison. Here are some of the reasons:

1) The intern is learning for the first time to make independent medical decisions. No matter how senior, skilled, or knowledgeable the ICU nurse is, the nurse is NOT there to make high-level management decisions. The ICU attending is making those decisions and managing the overall care.

2) The ICU nurse works in ONE care area: the ICU. The intern has to come up to speed on how things are done in one area, and then must start over in a new area the next month. Interns rotate through a number of different areas, depending on the type of internship. I did ICU, pediatrics, surgery, obstetrics, medicine, cardiology, etc. On each of those units, I became that doctor (e.g., on OB I evaluated pregnant women and delivered 50+ babies, on cardiology I did consults on cardiac issues and interpreted complex EKGs, on surgery, I operated). The nurses on each unit knew more than me about their respective areas -- at least in a logistical sense. Overall, I had a knowledge base that exceeded any given nurse. Take a nurse from the ICU and put her on OB, she would be clueless, but I as the intern would be functional (even if marginally so) in each of those environments. The broad training helps interns to develop an integrated, comprehensive view of medicine.

3) Comparing an intern to a seasoned ICU nurse is like comparing a West Point cadet to a Master Chief officer. You need to compare the general to the master chief officer. Or, you can compare the West Point cadet to the boot camp trainee for enlisted soldiers. In my ICU experience, I came across some fantastic, intelligent, experienced ICU nurses. The new ones (i.e., the freshly minted, fully qualified RNs) were often more clueless than interns (i.e, physicians at the beginning of their real clinical training).

I view the breakdown of physician education like this:
1) University: here you become educated in the general sense, you develop critical thinking skills, and an educated lens through which to view the world. You also learn the fundamentals of science that will be required in medical school.

2) Medical school (first 2 years): This is like a big vocabulary lesson. You learn the words and basic concepts of medicine, but you are useless in a clinical environment.

3) Medical school (clinical years): This is a 2-year long orientation to the clinical environment in different areas of medicine. You will begin to develop a process for diagnoses and treatment, but you are still generally useless in a clinical environment.

4) Intership: where the rubber meets the road. It is a trial-by-fire that cannot be understood by someone who has not gone through it. It is here that you slowly develop the thought process of a real physician. By the end, you may not have the specific knowledge or skills to solve a problem, but you know how you will stabilize the patient and get the resources that the patient needs.

5) Residency: this is the in-depth specialty training
6) Fellowship: for the development of deep expertise in a subspecialty of your field.

Now you might argue that all of this well-roundedness is irrelevant to the OR. And I would disagree with you.

If I am taking care of a patient with CHF, I can get the patient out of the OR alive just as well as you can. But I am tailoring my anesthetic with considerations to the treatment plan of medicine team that will be taking care of him post-op, because once upon a time, I was on that team. I will understand his preop meds, because I was once in the position of prescribing them.

If I am taking care of a patient with end-stage COPD, I similarly will tailor my anesthetic not just to get the patient out of the OR alive, but to dove-tail into the treatment plan of the pulmonologist -- because I was once on the medicine team that took care of that patient on the ward.

That is a how I see things. I do not mean to sound demeaning at all, so please forgive me if I come across that way. I welcome your questions.
+1

[MmacFN]

Hey there!

I thought this was a nice write up.

I do have some comments and questions which are not intended to be in anyway attacking just looking to see how we view it differently.



Internship is the most trying year of a physician-in-training. An MD comes fresh out of medical school with a vast knowledge base, but rather limited experience on how to apply it to the bedside. This young, inexperienced physician is now asked to work tremendous hours (36-hour shifts, 80-100 hour work weeks). The exhaustion is tremendous. To add insult to injury, just as he begins to master an environment and a patient population in one care area, in just a month's time he is asked to move to a new care area and relearn things from scratch. (More on this below).

Geez., sounds like a nightmare for sure!



1) The intern is learning for the first time to make independent medical decisions. No matter how senior, skilled, or knowledgeable the ICU nurse is, the nurse is NOT there to make high-level management decisions. The ICU attending is making those decisions and managing the overall care.

I suppose it really depends on what RN role we are talkin g about as well as what hospital setting. You have likely seen exactly what you are explaining here since that is very common in academic centers. However in many ICUs there are no interns, residents, PAs or NPs it all comes down to the ICU RN to make decisions (especially at night) with information they have right on hand. Many of the physicians running these ICUs are not inhouse all the time and never at night at the vast majority of US hospitals. They rely heavily upon the ICU RN to make the right decision during a crisis and call them. It really isnt that uncommon.

Having said that, I want to reinforce what you said in that the critical care physicians is the one who manages the overall care and is ultimately responsible for it. Generally, the RNs at these types of hospitals make crisis decisions not total management decisions autonomously.

There are other roles where RNs make absolutely autonomous decisions with very sick patients. As a flight RN I did this every day but that is certainly the minority.


2) The ICU nurse works in ONE care area: the ICU. The intern has to come up to speed on how things are done in one area, and then must start over in a new area the next month. Interns rotate through a number of different areas, depending on the type of internship. I did ICU, pediatrics, surgery, obstetrics, medicine, cardiology, etc. On each of those units, I became that doctor (e.g., on OB I evaluated pregnant women and delivered 50+ babies, on cardiology I did consults on cardiac issues and interpreted complex EKGs, on surgery, I operated). The nurses on each unit knew more than me about their respective areas -- at least in a logistical sense. Overall, I had a knowledge base that exceeded any given nurse. Take a nurse from the ICU and put her on OB, she would be clueless, but I as the intern would be functional (even if marginally so) in each of those environments. The broad training helps interns to develop an integrated, comprehensive view of medicine.

I generally agree with what you have said here. The exception to that would of course be the RNs who didnt just work in one place their whole career or were flight RNs expected to do all of this. It really depends upon the experience of the RN and how "a-type" and motivated they are to learn the whys. While I do think in comparison to the person who works in the ICU a couple years and noowhere else the intern would be better rounded. Having said that, the functional level anyone gains in 6 weeks is extremely limited, i think we can both agree on that.


3) Comparing an intern to a seasoned ICU nurse is like comparing a West Point cadet to a Master Chief officer. You need to compare the general to the master chief officer. Or, you can compare the West Point cadet to the boot camp trainee for enlisted soldiers. In my ICU experience, I came across some fantastic, intelligent, experienced ICU nurses. The new ones (i.e., the freshly minted, fully qualified RNs) were often more clueless than interns (i.e, physicians at the beginning of their real clinical training).

I certainly agree with the last statement about the new ones. 100%. However the first statement i cant entirely agree with (it might just be the terminology that rubs me the wrong way). It is too dependent upon the intern and the RNs personality and motivation to make that distinction. Generally, after a decade of seeing med students, residents and interns my assessment of interns is that they are just trying to get through these rotations because they are so stressed. I cant see how that allows someone to learn alot though i have seen some AMAZINGLY stellar ones (better than some residents in the same place). Again, just comes down to personality.


1) University: here you become educated in the general sense, you develop critical thinking skills, and an educated lens through which to view the world. You also learn the fundamentals of science that will be required in medical school.


If I am taking care of a patient with CHF, I can get the patient out of the OR alive just as well as you can. But I am tailoring my anesthetic with considerations to the treatment plan of medicine team that will be taking care of him post-op, because once upon a time, I was on that team. I will understand his preop meds, because I was once in the position of prescribing them.

Well, lets be real honest here. 6 weeks taking care of patients as an intern does not mean a whole lot to me. I have taken care of thousands of patients with CHF and various other severe conditions. I did it as part of a team in the ER/ICU and in an autonomous role in the helicopter and fixed wing. I now do it in the OR everyday (average age of my pts = 78). I know how to take care of these patients much better than any intern ever did or would after 6 weeks. I am not saying this to be in anyway insulting, to me it is simply a statement of fact. I learned for the best (nurses and physicians) and am someone who always knows the whys and hows. Its just how i roll. I could say the same for the COPD example you mentioned.

SO while i certainly have alot of respect for physicians and their training I do believe there is alot more to this than simply the background education. I do believe alot of the differences come down to motivation and personality type when looking at medical students/interns/residents and nurses. Some RNs will never, ever care to understand why but a med student/intern/resident is FORCED to. I believe that many more physicians are the motivated type A personality than RNs and part of that is the weeding process which is medicine. However, that does not mean all RNs cannot achieve this level of knowledge and understanding as that is out there free to learn if someone wants to.

Dont you think?

Again, excellent post and i really do appreciate you taking the time to come here! I hope we have lots of great conversations!

[Skeebum]

I agree with this, although perhaps in a different sense than you had intended. Interns do rely a lot on team members, especially intelligent, experienced ICU nurses! Let me give a little perspective on this:

Internship is the most trying year of a physician-in-training. An MD comes fresh out of medical school with a vast knowledge base, but rather limited experience on how to apply it to the bedside. This young, inexperienced physician is now asked to work tremendous hours (36-hour shifts, 80-100 hour work weeks). The exhaustion is tremendous. To add insult to injury, just as he begins to master an environment and a patient population in one care area, in just a month's time he is asked to move to a new care area and relearn things from scratch. (More on this below).

As such, the smart intern has no choice but rely on the experience of other, more experienced team members to guide him through this year. I remember seeking out the most experienced ICU nurses and soliciting their advice. It is the stupid intern that tries to do it without help.

That said, I do not think you can leap to the conclusion that ICU nurses are superior to interns. It is an apples-to-oranges comparison. Here are some of the reasons:

1) The intern is learning for the first time to make independent medical decisions. No matter how senior, skilled, or knowledgeable the ICU nurse is, the nurse is NOT there to make high-level management decisions. The ICU attending is making those decisions and managing the overall care.

2) The ICU nurse works in ONE care area: the ICU. The intern has to come up to speed on how things are done in one area, and then must start over in a new area the next month. Interns rotate through a number of different areas, depending on the type of internship. I did ICU, pediatrics, surgery, obstetrics, medicine, cardiology, etc. On each of those units, I became that doctor (e.g., on OB I evaluated pregnant women and delivered 50+ babies, on cardiology I did consults on cardiac issues and interpreted complex EKGs, on surgery, I operated). The nurses on each unit knew more than me about their respective areas -- at least in a logistical sense. Overall, I had a knowledge base that exceeded any given nurse. Take a nurse from the ICU and put her on OB, she would be clueless, but I as the intern would be functional (even if marginally so) in each of those environments. The broad training helps interns to develop an integrated, comprehensive view of medicine.

3) Comparing an intern to a seasoned ICU nurse is like comparing a West Point cadet to a Master Chief officer. You need to compare the general to the master chief officer. Or, you can compare the West Point cadet to the boot camp trainee for enlisted soldiers. In my ICU experience, I came across some fantastic, intelligent, experienced ICU nurses. The new ones (i.e., the freshly minted, fully qualified RNs) were often more clueless than interns (i.e, physicians at the beginning of their real clinical training).

I view the breakdown of physician education like this:
1) University: here you become educated in the general sense, you develop critical thinking skills, and an educated lens through which to view the world. You also learn the fundamentals of science that will be required in medical school.

2) Medical school (first 2 years): This is like a big vocabulary lesson. You learn the words and basic concepts of medicine, but you are useless in a clinical environment.

3) Medical school (clinical years): This is a 2-year long orientation to the clinical environment in different areas of medicine. You will begin to develop a process for diagnoses and treatment, but you are still generally useless in a clinical environment.

4) Intership: where the rubber meets the road. It is a trial-by-fire that cannot be understood by someone who has not gone through it. It is here that you slowly develop the thought process of a real physician. By the end, you may not have the specific knowledge or skills to solve a problem, but you know how you will stabilize the patient and get the resources that the patient needs.

5) Residency: this is the in-depth specialty training
6) Fellowship: for the development of deep expertise in a subspecialty of your field.

Now you might argue that all of this well-roundedness is irrelevant to the OR. And I would disagree with you.

If I am taking care of a patient with CHF, I can get the patient out of the OR alive just as well as you can. But I am tailoring my anesthetic with considerations to the treatment plan of medicine team that will be taking care of him post-op, because once upon a time, I was on that team. I will understand his preop meds, because I was once in the position of prescribing them.

If I am taking care of a patient with end-stage COPD, I similarly will tailor my anesthetic not just to get the patient out of the OR alive, but to dove-tail into the treatment plan of the pulmonologist -- because I was once on the medicine team that took care of that patient on the ward.

That is a how I see things. I do not mean to sound demeaning at all, so please forgive me if I come across that way. I welcome your questions.
Hey Res,

I see where you are coming from.

But please keep in mind, I was, once upon a time, part of that team also.

I spent 6 years helping to develop that treatment plan for the guy with CHF. I too cared for the lady who treated her COPD with cigarettes. I was the one at the bedside, drawing, and reviewing, the q1hour labs on the ESRD patient, with cardiomyopathy, who was vented, on a balloon pump and getting CVVH.

If I had to guess, I made more “constructive suggestions” to treatment plans, then you independently wrote orders for as an intern. (That is not intended as a slight……………just my opinion).

IMO you are discounting our ICU training, just a tad.

With that said, there is an undercurrent within the Nurse Anesthesia community to up the minimum ICU time requirement. Something I support BTW (different topic, well covered in other threads).

Skee

1)Thanks Res, for your frank responses
2)Thanks to all for keeping this civil, we really need more of this.

[MmacFN]

Dude

Even if we dont agree on everything, i certainly respect your opinion. Thanks for posting ;)

Nothing you said here is ban worthy that is for sure!

Just to give you some insight as to what CRNAs can do.., i do all asa 3&4s (and a few 5s) independently in a large metro area with no supervision. I work in a group owned by MDs (see i can play nice!) and they do the hearts where i work we do everything else. This includes crani's, major backs, major vascular and everything in between. My patients average age is 78 and many have severe CHF, severe COPD, EFs < 15%, acute/chronic renal failure etc etc, you name it we have it. Our group took over from an all MD group and it has been a little over 3 years. During that time the complication rate has actually dropped, mortality stayed the same, the efficiency rate has increased, the patient satisfaction scores with anesthesia have increased, the PONV rate dropped, post op pain complaints decreased, the surgeons are happier as are the PACU staff and the OR staff and the hospital is ecstatic.

I dont work shifts. i work till the cases are done and i take call. When someone is sick and i might be off i come in to cover the contract because that is what you do. I know some CRNAs like your friend have a cushy job with shifts and limited need to critically think, but that does not represent all of us or what we want and/or are capable of.

Now, i am not saying every CRNA could work here, in fact we have booted some who just cannot hack it. However, not every MD can either as we have booted some of them who cant as well. So there is alot more to all this than those on SDN say and the real world is very different from academics you see or the job your relative has. Its much different than how they are painting it over there.

Great discussion and good post!


I'll chime in as well. I am a CA-1 (PGY-2) that is roughly 6 months into my anesthesia training. I have an immediate family member that is a CRNA (private practice). I will try to express myself without being inflammatory. There is obviously a lot of stuff that I disagree with on this board, however I do think that there is a place for the ACT model.

I tend to agree with AnesRes sentiments. Our training is different. From my experience, my intern year taught me how to deal with most issues a doctor would face on the floors. Recognizing SICK from non-SICK, and knowing how to deal with them accordingly. As an intern in the ICU, you learn which nurses "get it" and which ones don't really quickly. As I'm sure the nurses learn the same about the interns. I'm sure a lot of generalizations are made by both sides when they witness the other side flounder or do something ridiculous.

That being said, I was a bit offended when I read on a different thread that as interns we learn what nurses already know. Just by talking with my immediate family member (who was an ICU nurse for 2 years before becoming a CRNA) I know that this is NOT true. Also, years in the ICU does not necessarily equate with knowledge in medicine. How many times did I admit numerous patients to the ICU while a lot of the ICU nurses sat around on computers during the night. Don't get me wrong, settling in a patient into the ICU takes a crazy amount of work which I respect. But that work is different from admitting and writing orders, getting pimped by upper level residents/attendings about management, and then having to round the next day and get pimped more - long after the night-shift nurses are home sleeping. I rarely would see a nurse trying to further his/her education while in the ICU unless they were studying for the GRE to become a mid-level practitioner (and most of the time this was studying GRE books, not medicine).

The things that nurses do have an edge on are the every day skills of an anesthesia provider. Setting up pumps/drips, administering medications, starting IVs, and many of the other technical skills that most interns don't do much of (especially at large academic institutions). I think that sometimes interns and early CA-1s show a LACK of these skills, and it is assumed that this is a LACK of knowledge. This is just being in a new role, which would take anyone time to adjust to. No one comes out of the womb knowing how to start an IV or set up an epinephrine drip.

Taking the knowledge we get as medical students and the training we get as anesthesiology residents, I believe that we are trained to diagnose and treat any issues that might be presented to us in the clinical setting. The background knowledge we have provides a broad foundation to consider all aspects when caring for the patient. I honestly believe that nursing school and ICU experience do NOT provide this. As a simple reference, I cringed when I read something about solution tonicity having to do with pH on this board. These are two concepts I would hope that anyone practicing in anesthesia would have down cold. These are the things that are hammered into us during our medical training.

As far as the studies proving equivalent outcomes, I believe that we are fortunate to provide anesthesia in a time when it is very safe. Especially safe for healthy ASA-1/2s having non-complicated procedures. I believe that this is mostly what is done in rural areas where CRNAs practice independently, and I believe that this was what was studied. Am I OK with independent CRNA practice? Absolutely NOT, but I have witnessed it occurring. Just as I have scrubbed in with a rural family medicine physician performing a c-section. There is a NEED for rural healthcare, and MDs in general have shot ourselves in the foot by not wanting to practice in rural areas. I think that there is a gap in logic when one tries to generalize the outcomes to these studies to other patient populations. The funding of these studies is a bit suspect as well, as we have often seen different outcomes to studies based on who/where the research is done (beta blockade for CHF, etc.).

I have discussed a lot of this with my immediate family member who is a CRNA, who agrees with pretty much all that I have said. This family member does not wish to practice independently, nor do any of his/her colleagues in the group. Just from this, I would assume that most CRNAs are not interested in independent practice. After all, my family member makes roughly $120k yearly working a flexible 36 hours per week. Hardly anything to complain about.

Lastly, I feel like the term MDA tries to blur the line between CRNA and MD. Whether it is an insurance term or not, I feel that it is often used just to get on our nerves. Which, if that is the intention, solid work. :) MD would be just fine, just as it is for the rest of my medical school class, regardless of specialty.

Alright...enough of my rambling. I'm sure that my opinions have made some blood boil, but I'm just trying to give our (anesthesiology residents) perspective. I have tried not to say anything ban-worthy, but if I do get banned, I will not post again. I'm not one to be an unwelcome houseguest.

Starting arguments is not my intention but defending my choice of career is something I will stand by.

[Anesthesiologist]

Hi Malia and EsperRN,

Thank you for the questions. I will address the points you both raised in this single post.

You both raised the same valid question: does the knowledge decay over time to the point where the advantage of a well-rounded clinical education is rendered essentially moot? The answer is, of course, is that yes it can! If a physician chooses not to maintain that knowledge, then it will be lost. That being said, knowledge exists at different levels of abstraction. The details of medicine change quickly. The principles change too, although more slowly. The ability to have a detailed discussion with a physician consultant in another specialty based on a shared medical background -- that never changes. Furthermore, physician continuing education is addressed at refreshing these specific issues.

The example regarding your aunt is not quite apropos, because being a flight surgeon and directing occupational medicine have almost nothing to do with one another. However, anesthesia -- like emergency medicine and family practice -- is one of the broadest based medical specialties. I anesthetized children, parturients, and critically ill patients. All of that broad-based knowledge is relevant.

Malia, I do think that you are comparing apples and oranges.


Because you got a little bit of knowledge in a lot of areas (OB, peds, cards, ICU, etc), and I have a little more knowledge in ONE area (ICU, which may come into play more acutely in the operating room), how does that help you giving anesthesia?

You are comparing your experience as a NURSE in each of these areas to my comparison as a PHYSICIAN in each of these areas. I don't highlight that difference to be condescending or to reinforce some hierarchy. I do so to emphasize that physicians and nurses have different roles. It is a division of labor. Physicians focus more on strategy, nurses focus more on tactics. And no, I do not think you know more about ICU than me, because I can do the job of the ICU attending and ICU nurse and give anesthesia, and you can do only two of the three.

Or perhaps I should step back. When you say you "manage" sepsis, heart failure, and renal failure, what level of management are you referring to? How do you manage heart failure, specifically?










I agree with most of what you say. I agree that you have a more rounded education. But I also think that if you don't use it, you lose it. Sure, I was able to do rotations in pediatrics and OB, and pass with flying colors. But once I became an ICU nurse, all of that went out the window. ICU is a VERY specialized field, especially SURGICAL ICU. However, being able to recognize/analyze when a patient is getting worse/better, managing vents, gtts, analyzing labs, etc are ALL skills that are relevant to anesthesia and the OR. It's not called SURGICAL ICU for nothing....most of those patients are going to/coming back from surgery. Hence, they are often the same patients (besides ASA 1/2) that we see in the OR. We see patients with CHF, COPD, liver/renal failure, etc every single day in the SICU. We manage hypertensive, septic, hypovolemic patients every day.

I guess what I don't understand is...how would your "tailoring" of a CHF patient anesthesia differ from mine? Because you got a little bit of knowledge in a lot of areas (OB, peds, cards, ICU, etc), and I have a little more knowledge in ONE area (ICU, which may come into play more acutely in the operating room), how does that help you giving anesthesia?

My aunt was a flight trauma surgeon for the army back in the day. Now she is the Director of Occ. Med at a hospital. She will be the first one to tell me that she remembers NOTHING but a distant memory when I talk to her about what I'm learning. I think that all that knowledge of random facts, diseases, etc may be useful at some point, but the reality of you remembering anything OTHER than what you use on a daily basis is slim to none.

[ya herd]

While I disagree with some of what you say, I think you did it in a very respectful tone.

I just want to comment on two things, as I have a very busy day and I need to stop procrastinating.

I agree that interns training is different than an ICU nurse experience. I'm not under the impression that an intern is learning was an ICU nurse already knows because I feel they are learning different things. Writing orders, getting pimped, etc is a much different experience. I agree that a ICU nurse is also learning many technical skills that interns tend to miss out on because they are too busy writing orders and getting pimped. However, I think that you are forgetting other experiences that an ICU nurse are getting. Many times the ICU nurse is taking care of a sick one on one patient, doing nothing but staring at monitors and the patient, recognizing those PVCs are a result of low K+, that heart rate jump is probably the result of a rebleed, that drop in BP is from too much propofol, the K+ cannot be correct until the Mg++ is, recognizing that the ventilator settings need to be changed (and how I should adjust them) according to blood gases. We are sitting there and listening to everything going on in that room for hours, just as in the OR. It really helps beef up those assessment skills, recognizing a change, and what that change is.

Also, at least on night shift with my unit, I was given a great deal of freedom to send down labs or draw an ABG without calling the resident if I thought some value was going to be off, as well as freedom in other areas.

I'm not saying ICU nursing is better, just different and that there are some areas that we get good experience with that you may not think about.


I would argue that ICU RN's not only have an upper hand in "setting up" epinephrine drips, but also in managing patients on them. The finer points of managing vasopressors, ionotropes, and chronotropes can be a tricky skill to master during anesthesia training and ICU nurses do it every day. i.e. A patient in end stage heart failure with epi, levophed, and dopamine running and the RN has orders to "titrate to map > 60". Titrating those drips is NOT low level decision making. It involves an understanding of cardiac physiology and advanced hemodynamics. Anyway, I do believe that an ICU RN from a good unit has excellent experience in understanding and applying these concepts long before they enter anesthesia school. And one with a few years of good ICU experience probably will more vasoprssor drips (other than neo of course) that you will during your residency. (depending on how heavy your heart rotation is)

In any case, I appreciate your respectful postings and desire for open dialogue.

I think that both of these are good points.

As far as the first point -- Agreed. Nothing is better than an ICU nurse on top of his/her shiz and who makes valuable input to the patient's care.

As far as the second point -- Also agreed. The subtle nuances of titrating pressors is no small task. The good ICU nurses know WHY one pressor is chosen over another, as well as how to titrate it. I would argue that a physician's training would make this learning process a bit quicker, and that by the end of residency an anesthesiology resident should certainly be capable of this.

These are both small examples. My hope is that anesthesiology residency trains an anesthesiologist to function at a high level, just as CRNA training does with CRNAs. The training is completely different, but the jobs are also completely different. I think the quibbling comes to surface when the roles of each are crossed by one another (i.e. - an anesthesiologist trying to micromanage inane aspects of care, or a CRNA oversteps the bounds of his/her training).

As far as "defending" what I do....I guess its only a natural feeling after reading some stuff on this board. I didn't mean to step on your toes or to turn this thread into a flame war. I'll try to tone it down.

[maliggs]

Hi Malia and EsperRN,

Thank you for the questions. I will address the points you both raised in this single post.

You both raised the same valid question: does the knowledge decay over time to the point where the advantage of a well-rounded clinical education is rendered essentially moot? The answer is, of course, is that yes it can! If a physician chooses not to maintain that knowledge, then it will be lost. That being said, knowledge exists at different levels of abstraction. The details of medicine change quickly. The principles change too, although more slowly. The ability to have a detailed discussion with a physician consultant in another specialty based on a shared medical background -- that never changes. Furthermore, physician continuing education is addressed at refreshing these specific issues.

The example regarding your aunt is not quite apropos, because being a flight surgeon and directing occupational medicine have almost nothing to do with one another. However, anesthesia -- like emergency medicine and family practice -- is one of the broadest based medical specialties. I anesthetized children, parturients, and critically ill patients. All of that broad-based knowledge is relevant.

Malia, I do think that you are comparing apples and oranges.



You are comparing your experience as a NURSE in each of these areas to my comparison as a PHYSICIAN in each of these areas. I don't highlight that difference to be condescending or to reinforce some hierarchy. I do so to emphasize that physicians and nurses have different roles. It is a division of labor. Physicians focus more on strategy, nurses focus more on tactics. And no, I do not think you know more about ICU than me, because I can do the job of the ICU attending and ICU nurse and give anesthesia, and you can do only two of the three.Or perhaps I should step back. When you say you "manage" sepsis, heart failure, and renal failure, what level of management are you referring to? How do you manage heart failure, specifically?

I guess I didn't clarify that I'm still speaking about an intern in the ICU versus an ICU nurse. I'm not speaking about a board certified critical care/anesthesia attending. I absolute appreciate the CC attendings that I've worked with in the ICU. However, I think that interns are just trying to keep their heads above water. They're stressed, they're disorganized, they're overworked and fatigued. I saw an intern attempt to put in a central line after 30+ hours working and he started crying and left! And I don't blame him, I cannot imagine the feeling. Although Mike and others have met interns that exceed expectations, I have not. And I realize that anesthesia is absolutely a broad specialty. All I was saying with the comparison is that I think if you don't use what you've been taught, you lose it. I have a good friend who is an interventional cardiologist, and he says the exact same thing. Once you specialize in a field, your continuing education tends to focus on your specialty, correct?

I agree with what others have said: I think that our ICU training is discounted a bit by many. I worked in critical care transport (not flight, but ambulance) where I was the decision maker if a patient took a turn for the worse. I'm not saying this because I feel the need to defend myself, only to show that the nurses who go to anesthesia school are usually the ones that think for themselves, have an internal desire to acquire more knowledge, and who excel in critical thinking. The ICU nurses that are reading magazines, talking on the phone, etc... are NOT the ones that apply to anesthesia school.

I can appreciate the education and knowledge that an MD has. And I give them the respect they deserve. I was simply speaking about interns (as this original post was about interns) based on my personal experience with them. I wouldn't leave them alone with my sick patient in the ICU.

[sandmanpk]

Okay, I guess I'll have to be the one to get mean and nasty...........Just kidding. Excellent thread, very informative and I've learned a great deal about anesthesia residency.

[Anesthesiologist]

Hi Mike,

I agree generally with everything you said. Frankly, you sound like a really outstanding CRNA based on this post and some of your other posts that I have read. It is without question that someone with your experience would outclass an intern in many of these areas.

I think a lot of the CRNA vs. MD discussion though focuses on the average practitioners in each category. After all, there is standardized training and standardized certifications, so that we can make some reasonable inferences on someone's abilities if we do not know them personallly.

Your experience is by no means average.




Hey there!

I thought this was a nice write up.

I do have some comments and questions which are not intended to be in anyway attacking just looking to see how we view it differently.




Geez., sounds like a nightmare for sure!




I suppose it really depends on what RN role we are talkin g about as well as what hospital setting. You have likely seen exactly what you are explaining here since that is very common in academic centers. However in many ICUs there are no interns, residents, PAs or NPs it all comes down to the ICU RN to make decisions (especially at night) with information they have right on hand. Many of the physicians running these ICUs are not inhouse all the time and never at night at the vast majority of US hospitals. They rely heavily upon the ICU RN to make the right decision during a crisis and call them. It really isnt that uncommon.

Having said that, I want to reinforce what you said in that the critical care physicians is the one who manages the overall care and is ultimately responsible for it. Generally, the RNs at these types of hospitals make crisis decisions not total management decisions autonomously.

There are other roles where RNs make absolutely autonomous decisions with very sick patients. As a flight RN I did this every day but that is certainly the minority.



I generally agree with what you have said here. The exception to that would of course be the RNs who didnt just work in one place their whole career or were flight RNs expected to do all of this. It really depends upon the experience of the RN and how "a-type" and motivated they are to learn the whys. While I do think in comparison to the person who works in the ICU a couple years and noowhere else the intern would be better rounded. Having said that, the functional level anyone gains in 6 weeks is extremely limited, i think we can both agree on that.



I certainly agree with the last statement about the new ones. 100%. However the first statement i cant entirely agree with (it might just be the terminology that rubs me the wrong way). It is too dependent upon the intern and the RNs personality and motivation to make that distinction. Generally, after a decade of seeing med students, residents and interns my assessment of interns is that they are just trying to get through these rotations because they are so stressed. I cant see how that allows someone to learn alot though i have seen some AMAZINGLY stellar ones (better than some residents in the same place). Again, just comes down to personality.





Well, lets be real honest here. 6 weeks taking care of patients as an intern does not mean a whole lot to me. I have taken care of thousands of patients with CHF and various other severe conditions. I did it as part of a team in the ER/ICU and in an autonomous role in the helicopter and fixed wing. I now do it in the OR everyday (average age of my pts = 78). I know how to take care of these patients much better than any intern ever did or would after 6 weeks. I am not saying this to be in anyway insulting, to me it is simply a statement of fact. I learned for the best (nurses and physicians) and am someone who always knows the whys and hows. Its just how i roll. I could say the same for the COPD example you mentioned.

SO while i certainly have alot of respect for physicians and their training I do believe there is alot more to this than simply the background education. I do believe alot of the differences come down to motivation and personality type when looking at medical students/interns/residents and nurses. Some RNs will never, ever care to understand why but a med student/intern/resident is FORCED to. I believe that many more physicians are the motivated type A personality than RNs and part of that is the weeding process which is medicine. However, that does not mean all RNs cannot achieve this level of knowledge and understanding as that is out there free to learn if someone wants to.

Dont you think?

Again, excellent post and i really do appreciate you taking the time to come here! I hope we have lots of great conversations!

[Anesthesiologist]

We are on generally the same page then. Like I said, in my training, I came to respect the expertise of experienced ICU nurses. I do not discount it.




I guess I didn't clarify that I'm still speaking about an intern in the ICU versus an ICU nurse. I'm not speaking about a board certified critical care/anesthesia attending. I absolute appreciate the CC attendings that I've worked with in the ICU. However, I think that interns are just trying to keep their heads above water. They're stressed, they're disorganized, they're overworked and fatigued. I saw an intern attempt to put in a central line after 30+ hours working and he started crying and left! And I don't blame him, I cannot imagine the feeling. Although Mike and others have met interns that exceed expectations, I have not. And I realize that anesthesia is absolutely a broad specialty. All I was saying with the comparison is that I think if you don't use what you've been taught, you lose it. I have a good friend who is an interventional cardiologist, and he says the exact same thing. Once you specialize in a field, your continuing education tends to focus on your specialty, correct?

I agree with what others have said: I think that our ICU training is discounted a bit by many. I worked in critical care transport (not flight, but ambulance) where I was the decision maker if a patient took a turn for the worse. I'm not saying this because I feel the need to defend myself, only to show that the nurses who go to anesthesia school are usually the ones that think for themselves, have an internal desire to acquire more knowledge, and who excel in critical thinking. The ICU nurses that are reading magazines, talking on the phone, etc... are NOT the ones that apply to anesthesia school.

I can appreciate the education and knowledge that an MD has. And I give them the respect they deserve. I was simply speaking about interns (as this original post was about interns) based on my personal experience with them. I wouldn't leave them alone with my sick patient in the ICU.

[Anesthesiologist]

BTW, how do i change my profile from anesthesia resident to anesthesia attending?

[ADMIN]

Oops sorry man, fixed ;)


BTW, how do i change my profile from anesthesia resident to anesthesia attending?

[Anthony]

Open dialog is the only way in which all of us can come to an objective understanding of both POVs. In saying this, because of the dynamics of training, we face very contentious practice topics in which both feel passionately in defending. I have no illusions that this will continue for the foreseeable future, but it is refreshing to have this exchange.

If calmer minds can continue to prevail, let me ask this.....do you (MDs) see a middle ground where both MDs and CRNAs might agree upon?

[Esper]

Great discussion. I especially appreciate all of you not considering my questions inflammatory and responding in a way that promotes your profession by exemplifying your positive traits. It is a very sensitive subject and it feels to be handled well.

I'm glad you defend your profession yet come here to speak respectfully because it can only make us all better to have these conversations.

[MmacFN]

Hey

Thanks for the compliments!

I agree my experience is a bit, unusual, however I work with many CRNAs who do excellent yet do not have the same background as I do. I certainly do not discount the medical training, internship and residency physicians have to endure. I also do not think every CRNA is ready, willing or able to work in an autonomous manner but I have found that those who cannot do it get washed out of practices where they cant function at that level. To a lesser degree there are MDs who fit that same statement. Im sure you know fellow MDs as i know CRNAs you would never let put anyone you know to sleep. Why do they suck? Why are others amazing?

Sometimes I think personal motivation and 'drive' to understand is what makes great practitioners on both sides. Why has the initial edge? Im not sure how to define that!

Great discussion!






Hi Mike,

I agree generally with everything you said. Frankly, you sound like a really outstanding CRNA based on this post and some of your other posts that I have read. It is without question that someone with your experience would outclass an intern in many of these areas.

I think a lot of the CRNA vs. MD discussion though focuses on the average practitioners in each category. After all, there is standardized training and standardized certifications, so that we can make some reasonable inferences on someone's abilities if we do not know them personallly.

Your experience is by no means average.

[captgaston]

Well, welcome to both of our new MDAs (kidding... sorry....) I never use that term BTW...

I have a question that was raised during a discussion with a senior buisiness director of a large Anesthesia firm. His insight indicates that the shrinking reinbursment may equate to MD oversight of almost double the ORs in the near future that is currently accepted as a safe ratio. Have any of the MDs reading this thread heard of such a change in the model, and what is the opinion from your viewpoint on the changes we as providers will face with such changes in reinbursement?

[Caffiene]

I have been lurking on this site for a while and I have to say that this is probably one of the most interesting blogs that I have read thus far. As a new SRNA in my didactic phase I have been a little apprehensive about entering the clinical setting ( with all of the recent newspaper articles etc..). Regarding experience goes, mine is definitely not the ordinary. Prior to my 5 years in the cardiac surgery and General Surgery ICU arena, I worked as a Pulmonary Functions Technologist(PFT). A technical job that few know about which is credentialed by the National Board of Respiratory Care. To get to the point, I have a close family member who is an Anesthesiologist. (A fantastic role model and mentor). He has been providing anesthesia for a very long time. During his residency he performed the open drop either technique. My jaw drops when talks about giving halothane via insufflation and titrating to palpable ectopy.

Prior to me entering nursing school, one of my roles as a PFT was to manage a stat abg and co-oximetry lab at night as well as perform arterial punctures. One night, there was a patient with severe benzocaine induced methemoglobinemia. At that point my knowledge was limited to Flow Volume loops and ABG's. Being the curious, non licensed aspiring RN that I was, I asked my family member to explain how a topical anesthetic could cause the oxidation of hemoglobin. He then told me he was not sure what methemoglobin was. This is coming from man that has been providing Anesthesia for nearly 40 years. On a side note, he works in a very restrictive setting where CRNA's cannot perform any regional. He was very receptive of me explaining it to him. However this goes to show that we all can learn from each other and that we all are succeptible to forgetting things even if it is something within our scope of practice. To think that he would remember something from his residency 30+ years ago (not pertinent to anesthesia) would be ridiculous.

[stanman1968]

I have got to ask this question what does all of this medical education bring to the table? Really not in general terms but real life clinical terms.

[Anesthesiologist]

I have got to ask this question what does all of this medical education bring to the table? Really not in general terms but real life clinical terms.

Fair question. I will give you a specific answer, but first let me preface my answer with a statement about disease management, in general.

Most significant disease is of a chronic nature. It evolves and is managed over the course of years to decades. A surgical operation is but a brief moment in the patient's lifetime. We are fortunate to have anesthetic drugs and techniques that makes anesthesia incredibly safe. Few patients suffer direct intraoperative injury -- at least by our current abilities to measure injury. (This may change as we develop methods to look for injury at the cellular level.) Most of the morbidity and mortality for critically ill patients occurs in the post-operative period (for example, respiratory failure, ventilator-associated pneumonia, cerebral vasopasm, perioperative MI, renal failure). This has some important implications.

Anesthesiologists have actually managed these post-operative complications -- either in the training or in their current careers. When I use the word "manage", I mean that physicians specify the treatment goals, dictate the management strategy, and specify the tactics that will be used to achieves these goals. Nurses "manage" the patient in another sense: they use the specified tactics to achieve intermediate management goals. This is not a statement about who is smarter. Rather, it is a statement on the standard division of labor.

As a physician, I manage intraoperative problems -- which CRNAs do. As a physician, I also manage post-operative problems -- which CRNAs do not. Now back to the original question: how is this relevant? My answer is that because I am familiar with post-operative problems, I am might be willing to tolerate sub-optimal intraoperative conditions or accept increased anesthetic risk in order to minimize post-operative complications. For example:

- I might decide to continue anticoagulants and to accept increased intraoperative bleeding, so that I can decrease the risk of thrombosis in a high-risk patient
- I might decide to place an epidural in a patient with an INR of 1.6 in a patient with pulmonary function that is so poor that the risk of prolonged respiratory failure is high.
- I might decide to tolerate intraoperative hypotension and relative hypovolemia in a patient with severe CHF, because i deem the risk of fluid overload and ischemia due to increased myocardial wall tension to be the greater risk.

These are just some examples, of which there are an infinite number. I take those risks based on an my medically informed opinion on the trade-offs. And If I guess wrong, and that epidural hematoma develops in the patient with the INR of 1.6, I will be able to defend my judgement as the domain expert, which society considers to be the physician specialist.

I recall when I was a PhD student, I was the one asking the cutting edge research questions. My PhD advisor was not as up to speed as i was on these research questions. However, that did not mean he had no value. On the contrary, his value was in seeing the bigger picture -- how did my project relate to other projects in our lab, and more importantly, how my project fit into the landscape of the entire field of research. I see the value of a physician anesthesiologist -- with his broad medical training -- as analogous.

[RAYMAN]

So then, we do the same job it seems. We do all of the above.

[armygas]

I have to chime in...... within the perioperative period there is no difference in the scope of practice between anesthesiologists and CRNAs..... absolutely no difference.

As a person who also has a PhD (neuroscience) I do not see the difference in "management".

The decisions made by both the CRNA and MD are the same.... The reason? Because they are taught from the same text and hospitals. The only thing that stops a CRNA from making those management decisions is local hospital policy.

[Anthony]

I thought we were just talking about background prep rather than scope of practice....

[Esper]

I have to disagree with your premise here. I'm being well trained didatically (all I can say since I start clinicals in Jan.) to consider these post op complications. Perhaps you think that one must manage these post op cases for weeks to grasp the concepts. We'll just have to disagree and call it opinion for now, but I assure you that I keep these things in mind as well and I know many CRNAs/SRNAs (often mandated for the SRNA) that do post op rounds to see how their anesthetic affected the patient in the long term. I personally plan on following up with as many of my anesthetics as I can in clinicals.

Query: have you experienced any snobbish behavior from docs in other specialties? I always wonder if the things I hear about docs talking about each other, like Emed is a glorified triage nurse, are true?


Fair question. I will give you a specific answer, but first let me preface my answer with a statement about disease management, in general.

Most significant disease is of a chronic nature. It evolves and is managed over the course of years to decades. A surgical operation is but a brief moment in the patient's lifetime. We are fortunate to have anesthetic drugs and techniques that makes anesthesia incredibly safe. Few patients suffer direct intraoperative injury -- at least by our current abilities to measure injury. (This may change as we develop methods to look for injury at the cellular level.) Most of the morbidity and mortality for critically ill patients occurs in the post-operative period (for example, respiratory failure, ventilator-associated pneumonia, cerebral vasopasm, perioperative MI, renal failure). This has some important implications.

Anesthesiologists have actually managed these post-operative complications -- either in the training or in their current careers. When I use the word "manage", I mean that physicians specify the treatment goals, dictate the management strategy, and specify the tactics that will be used to achieves these goals. Nurses "manage" the patient in another sense: they use the specified tactics to achieve intermediate management goals. This is not a statement about who is smarter. Rather, it is a statement on the standard division of labor.

As a physician, I manage intraoperative problems -- which CRNAs do. As a physician, I also manage post-operative problems -- which CRNAs do not. Now back to the original question: how is this relevant? My answer is that because I am familiar with post-operative problems, I am might be willing to tolerate sub-optimal intraoperative conditions or accept increased anesthetic risk in order to minimize post-operative complications. For example:

- I might decide to continue anticoagulants and to accept increased intraoperative bleeding, so that I can decrease the risk of thrombosis in a high-risk patient
- I might decide to place an epidural in a patient with an INR of 1.6 in a patient with pulmonary function that is so poor that the risk of prolonged respiratory failure is high.
- I might decide to tolerate intraoperative hypotension and relative hypovolemia in a patient with severe CHF, because i deem the risk of fluid overload and ischemia due to increased myocardial wall tension to be the greater risk.

These are just some examples, of which there are an infinite number. I take those risks based on an my medically informed opinion on the trade-offs. And If I guess wrong, and that epidural hematoma develops in the patient with the INR of 1.6, I will be able to defend my judgement as the domain expert, which society considers to be the physician specialist.

I recall when I was a PhD student, I was the one asking the cutting edge research questions. My PhD advisor was not as up to speed as i was on these research questions. However, that did not mean he had no value. On the contrary, his value was in seeing the bigger picture -- how did my project relate to other projects in our lab, and more importantly, how my project fit into the landscape of the entire field of research. I see the value of a physician anesthesiologist -- with his broad medical training -- as analogous.

[armygas]

I thought we were just talking about background prep rather than scope of practice....

The point of "management" was introduced thus it was addressed. :)

[JadamR15]

The point of "management" was introduced thus it was addressed. :)

Finer point:

The MD was contrasting management of patients by physicians and staff nurses. He was referencing Malia's statement of "We ICU nurses manage...." etc.

None the less, perioperative decision making by either group (CRNA or MD) should, ideally, be the same decision that is appropriate for the patient.

[JadamR15]

So then, we do the same job it seems. We do all of the above.


While CRNAs DO indeed DO all that the Anesthesiologist mentioned, I think Anes. was trying to differentiate his training with disease management as opposed to the ICU experience and the anesthesia training of the CRNA.

[armygas]

While CRNAs DO indeed DO all that the Anesthesiologist mentioned, I think Anes. was trying to differentiate his training with disease management as opposed to the ICU experience and the anesthesia training of the CRNA.

That is not how I perceived his statements.

[JadamR15]

That is not how I perceived his statements.


No biggie :).

[JadamR15]

I thought we were just talking about background prep rather than scope of practice....


Indeed. Scope of practice conversations invariably end in disagreement.

It's worthwhile to explore such things as long as no one thinks they're going to convince the other, as that clearly will not happen.

[RAYMAN]

While CRNAs DO indeed DO all that the Anesthesiologist mentioned, I think Anes. was trying to differentiate his training with disease management as opposed to the ICU experience and the anesthesia training of the CRNA.

Ditto Army's response. Jadam, do you think there are some magic texts or something that only MD's have access to? We use the same information and should use it in the same way. Science doesn't change when you walk into the hallowed halls of medical school. Perhaps you should hold yourself to a higher standard. I'm not dissing you, but you have to be able to do EVERYTHING he does when you graduate. I manage my patients exactly as he does. I take into consideration preoperative, intraoperative and postoperative concerns of disease states, just as he mentioned.

[JadamR15]

Ditto Army's response. Jadam, do you think there are some magic texts or something that only MD's have access to? We use the same information and should use it in the same way. Science doesn't change when you walk into the hallowed halls of medical school. Perhaps you should hold yourself to a higher standard. I'm not dissing you, but you have to be able to do EVERYTHING he does when you graduate. I manage my patients exactly as he does. I take into consideration preoperative, intraoperative and postoperative concerns of disease states, just as he mentioned.

I was just clarifying what I saw as a disconnect in understanding. I perceived the statements differently I guess.

[Anesthesiologist]

That is not how I perceived his statements.

JadamR15's interpretation is how I meant for it to come across.

[RAYMAN]

JadamR15's interpretation is how I meant for it to come across.

Fair enough. Different journey with the same destination.

[Anesthesiologist]

This might just be an irreconciliable difference, but I am committing to keep this discourse civil, no matter the degree of disagreement :-)

There is a spectrum of care from OR to ICU in the critically ill patient. There is no imaginary sharp line dividing those two periods of care, on one side with the anesthesiologist and CRNA being equal, and on the other with the anesthesiologist/intensivist and ICU RN having distinct roles. It is a continuum of care, and I believe my continuum extenders further.

1) Do you believe that you can run an ICU?
2) Are physicians necessary at all in the ICU?
3) Do you believe that reading the same textbook confers the same degree of judgement?
4) Are you absolutely sure that there is no difference, when you have never done my job?


I don't think the argument reading the same texts has any merit. I believe that there is judgment that develops over time by seeing and making decisions about cases. I can (and have) read a surgery text. It probably was even the same text that my surgical colleagues read. I have even operated. I do not believe that makes me a surgeon.

Furthermore, if texts were all you needed, then we all wasted our money grandly on schooling.


I have to chime in...... within the perioperative period there is no difference in the scope of practice between anesthesiologists and CRNAs..... absolutely no difference.

As a person who also has a PhD (neuroscience) I do not see the difference in "management".

The decisions made by both the CRNA and MD are the same.... The reason? Because they are taught from the same text and hospitals. The only thing that stops a CRNA from making those management decisions is local hospital policy.

[snaggletooth]

... That being said, knowledge exists at different levels of abstraction. The details of medicine change quickly. The principles change too, although more slowly. The ability to have a detailed discussion with a physician consultant in another specialty based on a shared medical background -- that never changes. ...

What you describe is an "old boy's network" rather than something fundamentally different in our training. The practice differences are just around the edges, not nearly apples and oranges.

We have much more in common than what separates us

[RAYMAN]

This might just be an irreconciliable difference, but I am committing to keep this discourse civil, no matter the degree of disagreement :-)

There is a spectrum of care from OR to ICU in the critically ill patient. There is no imaginary sharp line dividing those two periods of care, on one side with the anesthesiologist and CRNA being equal, and on the other with the anesthesiologist/intensivist and ICU RN having distinct roles. It is a continuum of care, and I believe my continuum extenders further.

1) Do you believe that you can run an ICU?
2) Are physicians necessary at all in the ICU?
3) Do you believe that reading the same textbook confers the same degree of judgement?
4) Are you absolutely sure that there is no difference, when you have never done my job?


I don't think the argument reading the same texts has any merit. I believe that there is judgment that develops over time by seeing and making decisions about cases. I can (and have) read a surgery text. It probably was even the same text that my surgical colleagues read. I have even operated. I do not believe that makes me a surgeon.

Furthermore, if texts were all you needed, then we all wasted our money grandly on schooling.

Like I said, different road, same destination.

[armygas]

The only difference is that you may have a role analogous to the ICU intensivist outside the periop period however the comparison to a surgeon is not valid.

CRNAs and Anesthesiologists both read the same books and then train in anesthesia.

[Anesthesiologist]

Like I said, different road, same destination.

How do you know we are at the same destination, when you have never done the job of managing ICU patients. Is there a remote possibility that this confers an iota of additional insight into the management of patients? Any possibility whatsoever?

[Anesthesiologist]

The only difference is that you may have a role analogous to the ICU intensivist outside the periop period however the comparison to a surgeon is not valid.

CRNAs and Anesthesiologists both read the same books and then train in anesthesia.

Would you kindly respond to my specific questions?

[Anesthesiologist]

Hi experRN:

I think it is one thing to learn about the management in textbooks and the classroom. It is another to experience them. No, I do not think you need to manage them to "grasp" them, but the is a much more profound understanding of issues when you have to wrestle with them -- particularly in the gray areas where there is no clear cut answer. I understood heart failure when I studied it in school. I understood it A LOT MORE, when I had to manage it. If didactics were sufficient, then I wasted my time doing a residency; I should have just stayed home and read the book.

Regarding the snobbish behavior: In training I did experience that. Also, when I was an an academic attending, I experienced that as well. In private practice, the relationship is far more collegial.



I have to disagree with your premise here. I'm being well trained didatically (all I can say since I start clinicals in Jan.) to consider these post op complications. Perhaps you think that one must manage these post op cases for weeks to grasp the concepts. We'll just have to disagree and call it opinion for now, but I assure you that I keep these things in mind as well and I know many CRNAs/SRNAs (often mandated for the SRNA) that do post op rounds to see how their anesthetic affected the patient in the long term. I personally plan on following up with as many of my anesthetics as I can in clinicals.

Query: have you experienced any snobbish behavior from docs in other specialties? I always wonder if the things I hear about docs talking about each other, like Emed is a glorified triage nurse, are true?

[snaggletooth]

To the anesthesiologist, what is the standard ICU training for an anesthesia resident and did you do a fellowship or post doc?

[sandmanpk]

As a physician, I manage intraoperative problems -- which CRNAs do. As a physician, I also manage post-operative problems -- which CRNAs do not. Now back to the original question: how is this relevant? My answer is that because I am familiar with post-operative problems, I am might be willing to tolerate sub-optimal intraoperative conditions or accept increased anesthetic risk in order to minimize post-operative complications.

I work solo in a rural facility doing anesthesia for ASA I-IV patients. I manage post-op issues every week. You may not be familiar with this practice setting. Here you are essentially saying you are willing to accept increased anesthesia risk HOPING to minimize or reduce post-op complications. Keep in mind we all need to use evidence-based information in order to make the appropriate decisions. Let's look at the first scenario you posed: Continuing anticoagulants and accept incr. intraop bleeding in order to decr post-op thrombosis risk. This will depend on the surgery being performed, patient history, specific anticoagulant therapy, labs, etc. As an independent CRNA I can tell you I deal with the same issues. A study showed increased post-op subconjuctival hemorrhage in patients following phacoemulsifaction when they continued their antiplatelet drugs up until the day of surgery. Does that have any bearing on the patient who presents for a TECAB? No. My point is that I make the same decisions based on the literature, and my experience as a CRNA. I certainly don't follow a cook-book approach, and blindly do anesthesia. I tailor my anesthesia to each patient.

I too may decide to place an epidural in a patient with a moderately increased INR if that is what is best for the patient intraop AND postop. Believe me, CRNAs do answer for the care we give. In a tort case, you may try and defend your decision as the domain expert, but it is negligence per se, and res ipsa loquitor that dominate the legal arena.

I appreciate your candor during this thread discussion, and hope that you too have learned a little about independent CRNA practice.

[RAYMAN]

How do you know we are at the same destination, when you have never done the job of managing ICU patients. Is there a remote possibility that this confers an iota of additional insight into the management of patients? Any possibility whatsoever?
You are changing the subject to icu management. I've never seen an anesthesiologist "manage" an icu patient outside of academia...most try hard to stay away. I was working daily with heart patients while you were waiting on pubes to grow...it's not like I had never been around it, read the text then experienced it. No huge epiphanies.

[Anesthesiologist]

The thread arrangement is a bit awkward on this forum. I will attempt to answer in just one place.

The core of the disagreement is whether an anesthesiologist's experience as a physician managing patients in other settings confers any additional advantage, when you (we) all have read the same books and all know the same medical words. I know you take into consideration disease states in your management. But to me, your knowledge is more theoretical, and an anesthesiologists knowledge is both theoretical AND experiential from a medical decision making standpoint. I find it hard to accept the argument that a particular experience doesnt matter, when that argument is coming from someone who hasn't actually had that experience.

To the other poster: the minimum ICU experience in an anesthesiologist's training is 4 months. A large portion of residents have done more. Then there is also the experience managing non-ICU patients on other floors. I argue this experience is also additive, because it is additional experience in developing differential diagnoses and making medical decisions.

I guess we just have to agree to disagree. What we need to find is a physician who was formerly a CRNA, and ask them what their opinion is.



Ditto Army's response. Jadam, do you think there are some magic texts or something that only MD's have access to? We use the same information and should use it in the same way. Science doesn't change when you walk into the hallowed halls of medical school. Perhaps you should hold yourself to a higher standard. I'm not dissing you, but you have to be able to do EVERYTHING he does when you graduate. I manage my patients exactly as he does. I take into consideration preoperative, intraoperative and postoperative concerns of disease states, just as he mentioned.

[Anesthesiologist]

You are changing the subject to icu management. I've never seen an anesthesiologist "manage" an icu patient outside of academia...most try hard to stay away. I was working daily with heart patients while you were waiting on pubes to grow...it's not like I had never been around it, read the text then experienced it. No huge epiphanies.

I am trying to keep this argument non-inflammatory. I am not trying to change the subject to ICU management.

The thrust of my argument is that having experience making real decisions about patients in settings other than the OR confers some insights about making decisions about those very same patients in the OR!

It is no wonder why people get so inflamed and polarized on SDN. I have promised to keep this civil, so I am going to take a break from the forum. I wish you a good evening.

[sandmanpk]

T




I don't think the argument reading the same texts has any merit. I believe that there is judgment that develops over time by seeing and making decisions about cases. I



You are exactly right that "judgment" develops with experience. I've done thousands of anesthetics, and managed a variety of preop, intraop, postop issues. If I've done 5,000 more anesthetics than you, for example, does that make more more or less capable of managing problems than yourself? Is that a reasonable conclusion? I agree that reading the same texts does not make any difference. It boils down to experience.

Now, as you know, many of the patients we manage pre,intra,post op are sick ICU patients. I as a CRNA am making all decisions regarding the care of that patient, and the surgeon looks to me to handle the care of said patient. I have been called by family physicians to manage a patient they have admitted to ICU. By manage I mean issues such as vent, lines, pressors, fluids, etc. No, I don't write diet orders, activity orders, dressing changes, or routine labs. That I leave to the FMD. Many times the internist will manage most issues, and may or may not ask for my assistance. As you know, many of us spent years in ICUs before entering anesthesia school. Our exposure and care during those years were/are of great benefit.

So, I would say that I have done those things you assume all CRNAs have not done. That being said, I can respect your skills in managing multiple ICU patients.

[sandmanpk]

What we need to find is a physician who was formerly a CRNA, and ask them what their opinion is.

Many of us know of one....but she was a lousy CRNA. Sorry, but there is a reason she left our camp. There may be some others, I don't know.

[snaggletooth]

What we need to find is a physician who was formerly a CRNA, and ask them what their opinion is
I've heard from one or two. I believe they made the switch for the autonomy, but don't recall discussion on qualifications/experience or practice differences

4 months in the ICU is precious little. I know, I've had 4 months in clinical and am just starting to get the feel for my training wheels. But I do agree that all experience is additive. I draw on my customer service experience daily (no kidding, no sarcasm ... it's all good)

3 or 4 of our intensivists were former anesthesiologists and one split their practice between the ICU and OR. But they all had critical care training beyond their anesthesia training.

[RAYMAN]

I am trying to keep this argument non-inflammatory. I am not trying to change the subject to ICU management.

The thrust of my argument is that having experience making real decisions about patients in settings other than the OR confers some insights about making decisions about those very same patients in the OR!

It is no wonder why people get so inflamed and polarized on SDN. I have promised to keep this civil, so I am going to take a break from the forum. I wish you a good evening.

Obviously my attempt at humor to illustrate my experience was poorly taken by you. We would all like to keep this civil, but you have seemingly turned this into a "I know more than you and you don't know what you don't know" discussion. I have a hard time believing you would come here with the only goal being dialoguge. I've worked with and work with a number of anesthesiologists who never pretend to know more than me or "put me in my place". None of that bs...it is a very cooperative atmosphere and we freely give advice back in forth. If they have an idea or thought, I'm all ears...also my input is valued and expected. Frankly though, I've yet to meet a mda who I'd want to put me or my family to sleep because every anesthetic I've seen them do has been sloppy and inattentive. I don't mean that in a mean way, just a fact.

[armygas]

Would you kindly respond to my specific questions?

When your questions compare apples to apples I will happily answer them

[deepz]

Obviously my attempt at humor to illustrate my experience was poorly taken by you. We would all like to keep this civil, but you have seemingly turned this into a "I know more than you and you don't know what you don't know" discussion. I have a hard time believing you would come here with the only goal being dialoguge. I've worked with and work with a number of anesthesiologists who never pretend to know more than me or "put me in my place". None of that bs...it is a very cooperative atmosphere and we freely give advice back in forth. If they have an idea or thought, I'm all ears...also my input is valued and expected. Frankly though, I've yet to meet a mda who I'd want to put me or my family to sleep because every anesthetic I've seen them do has been sloppy and inattentive. I don't mean that in a mean way, just a fact.


Yer not as dumb as yer avatar would make ya look.


:popcorn:

[Anesthesiologist]

Hi Rayman,

I think there is nothing to be gained except dialogue, when an anesthesiologist goes to a CRNA website to post. There is no money to be gained, nor is there any political goal to be won.

I suppose that when I am trying to defend my perspective that physician experience has value, and when your perspective is that physician experience has absolutely no value in this arena, then a heated exchange is almost inevitable. A pissing match is absolutely not what I want.

I think experience counts for a lot, and I respect the CRNA experience I have learned about by reading these forums. I do feel that some people here want to compare the cream-of-the-crop CRNA to the lousiest anesthesiologist known to man. However, I do know the opposite sin is committed on SDN.


Frankly though, I've yet to meet a mda who I'd want to put me or my family to sleep because every anesthetic I've seen them do has been sloppy and inattentive. I don't mean that in a mean way, just a fact.

This sort of statement begets that nasty broad generalizations spewed on SDN. Although in truth, to me, this statement is more a reflection of you than it is of the anesthesiologists you work with or the CRNA profession as a whole.

[stanman1968]

I do not think that you will find to many CRNA's trying to manage an ICU patient autonomously, collaboratively in rural America sure, I have but in one specific area not the whole enchilada, maybe some here have but not me. But the ICU is not the area of contention it is the OR. I compare myself to several anesthesiologists and I am just not impressed. Is it possible that the 12-15 MD that I have had to work at just suck? If that is really the case then medical anesthesia is in dire straits indeed. I have worked with 1-2 that are good but not better then me, and I do not consider myself cream of the crop ask anyone here and I am pretty vanilla.

[RAYMAN]

I'm not trying to belittle the anesthesiologist's residency experience in the least. I know it is rigorous, but it's not the only rigorous training program. Just trying to put things apples to apples. I know some brilliant anesthesiologists but I know some brilliant CRNA's as well. When I make comparisons of the anesthetic given I'm thinking of the average of each and the majority...not the best vs the worst. I maintain great relationships with my MD colleagues and we have mutually respective working relationships....but when my mother in law had surgery last week, I had one of my CRNA friends do her case....she did great....the original surgery she had a week prior was done by a MD at another facility...and she was miserable postop with about 48 hours of PONV......

[MmacFN]

I thought this was a very well written and TRUE statement.

While I do believe that there are limiting factors such as how little time a pre-residency MD gets with medical issues I think it could easily be said that the ICU RN might miss out of the general management 'bigger picture' which often happens long before and long after the ICU.

Generally, I take care of these same issues in my practice but I realize that not all CRNAs do thought just about all MDs do.

nice post.



Fair question. I will give you a specific answer, but first let me preface my answer with a statement about disease management, in general.

Most significant disease is of a chronic nature. It evolves and is managed over the course of years to decades. A surgical operation is but a brief moment in the patient's lifetime. We are fortunate to have anesthetic drugs and techniques that makes anesthesia incredibly safe. Few patients suffer direct intraoperative injury -- at least by our current abilities to measure injury. (This may change as we develop methods to look for injury at the cellular level.) Most of the morbidity and mortality for critically ill patients occurs in the post-operative period (for example, respiratory failure, ventilator-associated pneumonia, cerebral vasopasm, perioperative MI, renal failure). This has some important implications.

Anesthesiologists have actually managed these post-operative complications -- either in the training or in their current careers. When I use the word "manage", I mean that physicians specify the treatment goals, dictate the management strategy, and specify the tactics that will be used to achieves these goals. Nurses "manage" the patient in another sense: they use the specified tactics to achieve intermediate management goals. This is not a statement about who is smarter. Rather, it is a statement on the standard division of labor.

As a physician, I manage intraoperative problems -- which CRNAs do. As a physician, I also manage post-operative problems -- which CRNAs do not. Now back to the original question: how is this relevant? My answer is that because I am familiar with post-operative problems, I am might be willing to tolerate sub-optimal intraoperative conditions or accept increased anesthetic risk in order to minimize post-operative complications. For example:

- I might decide to continue anticoagulants and to accept increased intraoperative bleeding, so that I can decrease the risk of thrombosis in a high-risk patient
- I might decide to place an epidural in a patient with an INR of 1.6 in a patient with pulmonary function that is so poor that the risk of prolonged respiratory failure is high.
- I might decide to tolerate intraoperative hypotension and relative hypovolemia in a patient with severe CHF, because i deem the risk of fluid overload and ischemia due to increased myocardial wall tension to be the greater risk.

These are just some examples, of which there are an infinite number. I take those risks based on an my medically informed opinion on the trade-offs. And If I guess wrong, and that epidural hematoma develops in the patient with the INR of 1.6, I will be able to defend my judgement as the domain expert, which society considers to be the physician specialist.

I recall when I was a PhD student, I was the one asking the cutting edge research questions. My PhD advisor was not as up to speed as i was on these research questions. However, that did not mean he had no value. On the contrary, his value was in seeing the bigger picture -- how did my project relate to other projects in our lab, and more importantly, how my project fit into the landscape of the entire field of research. I see the value of a physician anesthesiologist -- with his broad medical training -- as analogous.


Fair question. I will give you a specific answer, but first let me preface my answer with a statement about disease management, in general.

Most significant disease is of a chronic nature. It evolves and is managed over the course of years to decades. A surgical operation is but a brief moment in the patient's lifetime. We are fortunate to have anesthetic drugs and techniques that makes anesthesia incredibly safe. Few patients suffer direct intraoperative injury -- at least by our current abilities to measure injury. (This may change as we develop methods to look for injury at the cellular level.) Most of the morbidity and mortality for critically ill patients occurs in the post-operative period (for example, respiratory failure, ventilator-associated pneumonia, cerebral vasopasm, perioperative MI, renal failure). This has some important implications.

Anesthesiologists have actually managed these post-operative complications -- either in the training or in their current careers. When I use the word "manage", I mean that physicians specify the treatment goals, dictate the management strategy, and specify the tactics that will be used to achieves these goals. Nurses "manage" the patient in another sense: they use the specified tactics to achieve intermediate management goals. This is not a statement about who is smarter. Rather, it is a statement on the standard division of labor.

As a physician, I manage intraoperative problems -- which CRNAs do. As a physician, I also manage post-operative problems -- which CRNAs do not. Now back to the original question: how is this relevant? My answer is that because I am familiar with post-operative problems, I am might be willing to tolerate sub-optimal intraoperative conditions or accept increased anesthetic risk in order to minimize post-operative complications. For example:

- I might decide to continue anticoagulants and to accept increased intraoperative bleeding, so that I can decrease the risk of thrombosis in a high-risk patient
- I might decide to place an epidural in a patient with an INR of 1.6 in a patient with pulmonary function that is so poor that the risk of prolonged respiratory failure is high.
- I might decide to tolerate intraoperative hypotension and relative hypovolemia in a patient with severe CHF, because i deem the risk of fluid overload and ischemia due to increased myocardial wall tension to be the greater risk.

These are just some examples, of which there are an infinite number. I take those risks based on an my medically informed opinion on the trade-offs. And If I guess wrong, and that epidural hematoma develops in the patient with the INR of 1.6, I will be able to defend my judgement as the domain expert, which society considers to be the physician specialist.

I recall when I was a PhD student, I was the one asking the cutting edge research questions. My PhD advisor was not as up to speed as i was on these research questions. However, that did not mean he had no value. On the contrary, his value was in seeing the bigger picture -- how did my project relate to other projects in our lab, and more importantly, how my project fit into the landscape of the entire field of research. I see the value of a physician anesthesiologist -- with his broad medical training -- as analogous.

[ethernaut]

What we need to find is a physician who was formerly a CRNA, and ask them what their opinion is.

i have spoken with a couple. all say the same thing. two different ball games in the grand scheme of things. i agree.

[Johnga]

This might just be an irreconciliable difference, but I am committing to keep this discourse civil, no matter the degree of disagreement :-)

There is a spectrum of care from OR to ICU in the critically ill patient. There is no imaginary sharp line dividing those two periods of care, on one side with the anesthesiologist and CRNA being equal, and on the other with the anesthesiologist/intensivist and ICU RN having distinct roles. It is a continuum of care, and I believe my continuum extenders further.

1) Do you believe that you can run an ICU?
2) Are physicians necessary at all in the ICU?
3) Do you believe that reading the same textbook confers the same degree of judgement?
4) Are you absolutely sure that there is no difference, when you have never done my job?


I don't think the argument reading the same texts has any merit. I believe that there is judgment that develops over time by seeing and making decisions about cases. I can (and have) read a surgery text. It probably was even the same text that my surgical colleagues read. I have even operated. I do not believe that makes me a surgeon.

Furthermore, if texts were all you needed, then we all wasted our money grandly on schooling.

I believe the spectrum of care in the critically ill patient begins prehospital and continues until discharge. Our role as CRNAs varies by facility and practice model, but typically deals w/preoperative assessment and optimization, followed by the operative and postanesthetic periods. It isn't that we are incapable of managing ICU patients or lack the education to do so, but our role is centered around the operative suite. The care provided outside of that environment is something that we learn by clinical practice and education before we are accepted into a CRNA program. Once we cross over into advanced practice we are no longer expected to manage patients in the ICU.

To answer your questions:
1) I probably could run an ICU, but not well. The majority of CNRAs on this site have worked in different ICUs for many years, supervising the staff and managing patients as charge nurses. They have much more ICU experience than I do and could undoubtedly do a much better job of it. For them, the ICU is as much (or more) of a familiar environment than the OR and are intimately familiar w/orders, protocols, management, and interventions in the ICU patient population.
2) Yes, I think physicians are necessary in the ICU. There is no nursing equivalent to an intensivist to follow patients and manage their care, however a critical care CNS would probably do very well in that evironment.
3) Reading a textbook doesn't confer the same degree of judgement, however understanding the material contained within it confers the same degree of knowledge of that text. A typical CRNA's judgement comes from applying that knowledge to their years of experience in the nursing management of critically ill patients just as you likely applied that knowledge to your patient experiences. Since your experiences are different than a CRNA's your view may be different in regards to patient management but your judgement may not be all that dissimilar, nor will the interventions you chose.
4) Without having done your job, it would be as difficult for me to make an accurate assessment of you as it would for you to do the same in regards to my position.

Welcome to the site. Hopefully we can gain some insight into one anothers' views and have some interesting dialogues.

[AnesRes2014]

I am sensing a lot of "Good Will Hunting" sentiment on the board with regards to self-directed learning, which is fantastic and should always be encouraged. That said, there is also the saying that "he who teaches himself has a fool for a master." Medicine (and nursing) has changed a lot in the last 100 years, not the least of which is regulatory oversight from a variety of angles. Certainly government regulation, but more important is the professional oversight provided by your peers. An organization of nurses is best qualified to dictate what constitutes good nursing care, just as physicians are responsible for dictating what constitutes good medical care. Yes, there is an aspect of "the fox guarding the chicken coop," but the alternatives (non-health care administrative types dictating medical practice) are equally wrought with problems. That battle is a major source of strife for current and aspiring doctors.

A little tangential, but to get back on track, I think Anesthesiologist's point is that self-directed learning is a small piece of the puzzle. You can read a surgery book and in your mind have mastered the concepts, but with no frame of reference your knowledge is markedly limited. "You don't know what you don't know," so to speak. Every once in awhile this comes up when someone botches a plastic surgery job in their garage and it makes the headline news.

The point is, I can't just read a book and become an anesthesiologist. I will have to sit for written and oral boards and receive approval from my future colleagues prior to being qualified to practice. I presume (and my question is), that there must be a similar sort of process prior to working as a CRNA.

Personally, I think it would be an interesting experiment to have MDs sit for CRNA boards (or equivalent) and vice versa, but there is no way in Hades that the ASA or the AANA would support such an experiment. Both sides would have far too much to lose depending on the outcome :)

[Esper]

What do you think of the CRNAs who had an ACNP and practiced in the ICU before attending an anesthesia program? I believe they function similarly to interns. Do you think they have this ability to manage intraop care with the postop physician in mind?

What if CRNA programs instituted a 60-80 hour per week, 6 month rotation in various ICUs? How would this affect your view?

[deepz]

Fraught is the word you're looking for.


I am sensing a lot of "Good Will Hunting" sentiment on the board with regards to self-directed learning, which is fantastic and should always be encouraged. That said, there is also the saying that "he who teaches himself has a fool for a master." Medicine (and nursing) has changed a lot in the last 100 years, not the least of which is regulatory oversight from a variety of angles. Certainly government regulation, but more important is the professional oversight provided by your peers. An organization of nurses is best qualified to dictate what constitutes good nursing care, just as physicians are responsible for dictating what constitutes good medical care. Yes, there is an aspect of "the fox guarding the chicken coop," but the alternatives (non-health care administrative types dictating medical practice) are equally wrought with problems. That battle is a major source of strife for current and aspiring doctors.

A little tangential, but to get back on track, I think Anesthesiologist's point is that self-directed learning is a small piece of the puzzle. You can read a surgery book and in your mind have mastered the concepts, but with no frame of reference your knowledge is markedly limited. "You don't know what you don't know," so to speak. Every once in awhile this comes up when someone botches a plastic surgery job in their garage and it makes the headline news.

The point is, I can't just read a book and become an anesthesiologist. I will have to sit for written and oral boards and receive approval from my future colleagues prior to being qualified to practice. I presume (and my question is), that there must be a similar sort of process prior to working as a CRNA.

Personally, I think it would be an interesting experiment to have MDs sit for CRNA boards (or equivalent) and vice versa, but there is no way in Hades that the ASA or the AANA would support such an experiment. Both sides would have far too much to lose depending on the outcome :)

[AnesRes2014]

Haha thanks. Are you sure you're not actually a pre-med?

[J-Dubya]

Personally, I think it would be an interesting experiment to have MDs sit for CRNA boards (or equivalent) and vice versa, but there is no way in Hades that the ASA or the AANA would support such an experiment. Both sides would have far too much to lose depending on the outcome :)

I'm more interested in comparing patient outcomes than debating whose education is better. It costs more to educate an MDA than a CRNA. Clearly there are areas where MDAs are better educated. So, I'm sure if you compared the two head-to-head, as you suggest, MDAs would be superior in some aspect of the testing.

However, I think the big question is do these differences in education matter in real life? EVERY study to date seems to say no, it just doesn't matter. In this era of rising healthcare costs, there is need to justify the more expensive eduction (and resulting higher pay) of the MDA. I think in most cases it can't be done.

[AnesRes2014]

I'm more interested in comparing patient outcomes than debating whose education is better. It costs more to educate an MDA than a CRNA. Clearly there are areas where MDAs are better educated. So, I'm sure if you compared the two head-to-head, as you suggest, MDAs would be superior in some aspect of the testing.

However, I think the big question is do these differences in education matter in real life? EVERY study to date seems to say no, it just doesn't matter. In this era of rising healthcare costs, there is need to justify the more expensive eduction (and resulting higher pay) of the MDA. I think in most cases it can't be done.

Bolded is 100% true, and couldn't agree more. As I mentioned earlier, I'm not going to delve into the plus/minus of the studies (I believe there is one in particular you are referring to), other than to say that any study is nothing more than an attempt to quantify/categorize/analyze what is happening in real life, and some of those are better than others. A prospective randomized controlled trial would be the gold standard, but my understanding is that there are no such studies out there.

Now, we make decisions in medicine based on incomplete data all the time out of necessity, but that doesn't mean that it is ideal. It is what it is. The problem (by my understanding) is that to design an RCT that would be powered enough to pick up differences in patient outcomes would not be logistically and financially feasible. And even if it were, such a study would still need the support of the ASA and the AANA, and the issue of whether or not either organization would support such a study remains.

Anyway, I am far outside the realm of my expertise on this topic, and venture into it if only to illustrate an intern's opinion/thought process on a topic relevant to our field. And I am fortunate in that my medical school has a fairly strong reputation for promoting evidence-based medicine/epidemiology/public health (and by extension, critically analyzing studies), as I can safely say that there is significant disparity with regards to that area of instruction between medical schools. So I know there are a large number of (vocal) physicians who are probably underinformed on the issue. I have no idea what kind of education you get in nursing/CRNA school with regards to that area, so I can't comment on the information level of the vocal voices from the other side :)

[J-Dubya]

Now, we make decisions in medicine based on incomplete data all the time out of necessity, but that doesn't mean that it is ideal. It is what it is. The problem (by my understanding) is that to design an RCT that would be powered enough to pick up differences in patient outcomes would not be logistically and financially feasible.

While it is true that because a anesthesia is so safe and complications are so incredibly rare in all settings (MDA only, ACT, CRNA only), a RCT big enough to pick up differences in outcomes is not practical. However, pointing out that this difficult to do because complications are so rare in all three setting hardly helps the MDA argument.

PCPs face the same task with NPs in the primary care setting. I.e prove that your better education = better results. If there is a major difference it should be easy to detect. But to argue that there MAY be a TINY difference that an high powered study so large that it would be impossible to do could detect, simply is not going to fly anymore. Too many people are looking at the cost of healthcare and they want to see evidence and the retrospective studies that have been done, while not perfect, are still very, very convincing.

If I were an intern, I would seek out a fellowship in cardiac, pedi, or intensive care (skip in blocks, that one is not going to fly). The days of MDA getting paid to supervise CRNAs doing bread and butter cases on healthy patients are just not going to last forever.

[MmacFN]

Totally agree.

As for understanding studies and research, it varies as widely in anesthesia school and nursing school as it does for your medical school examples im sure!


Bolded is 100% true, and couldn't agree more. As I mentioned earlier, I'm not going to delve into the plus/minus of the studies (I believe there is one in particular you are referring to), other than to say that any study is nothing more than an attempt to quantify/categorize/analyze what is happening in real life, and some of those are better than others. A prospective randomized controlled trial would be the gold standard, but my understanding is that there are no such studies out there.

Now, we make decisions in medicine based on incomplete data all the time out of necessity, but that doesn't mean that it is ideal. It is what it is. The problem (by my understanding) is that to design an RCT that would be powered enough to pick up differences in patient outcomes would not be logistically and financially feasible. And even if it were, such a study would still need the support of the ASA and the AANA, and the issue of whether or not either organization would support such a study remains.

Anyway, I am far outside the realm of my expertise on this topic, and venture into it if only to illustrate an intern's opinion/thought process on a topic relevant to our field. And I am fortunate in that my medical school has a fairly strong reputation for promoting evidence-based medicine/epidemiology/public health (and by extension, critically analyzing studies), as I can safely say that there is significant disparity with regards to that area of instruction between medical schools. So I know there are a large number of (vocal) physicians who are probably underinformed on the issue. I have no idea what kind of education you get in nursing/CRNA school with regards to that area, so I can't comment on the information level of the vocal voices from the other side :)

[Anesthesiologist]

Thank you for the measured and well-argued response, Johnga. I appreciate it, and it engenders respect and intellectual collegiality, even if we differ on the details. I am taking the time to construct a careful, respectful argument about what I perceive as our training differences. When someone replies simply with a curt "yup, so there is no difference", that response does not engender respect -- because it requires no intellect, experience, or knowledge of any sort to construct.

I will state my opinion for the record -- and I have sent a similar message to others in private:

I have disdain for the extreme points of views on both sides of the argument. I disagree with the generalizations often made on SDN that all nurses are stupid or are inferior to physicians, regardless of their experience. Likewise, I disagree with the extremists on this website that physician experience has no additional value, or the ridiculous statement that anesthesiologists just suck. These kind of viewpoints only serve to hamper meaningful discussion.


For the record, I do believe -- as others have stated here -- that experience in combination with intelligence results in the best anesthetists, whether it be CRNA or anesthesiologist. I can see from this site that there are some outstanding, highly capable able anesthetists here. I can easily imagine that some of them would be superior to a less-experienced anesthesiologist.

However, I cannot say that CRNAs as a whole are equivalent to anesthesiologists as a whole. You cannot take the shining example of the experienced, solo CRNA and compare him to the lousiest anesthesiologist, and then make a valid comparison about the two groups. I agree with the person who said we need data on whether or not the educational differences actually make a difference. Unfortunately, we don't have sufficient data, nor do we have ANY sufficiently constructed studies that can begin to address the issue. In the meantime, the best we have is well-argued opinions.

On a separate note, I do not think anesthesiologists are the biggest threat to your professional standing. We are too small in number to handle the anesthetic needs of the country. In my opinion, your biggest threat is the CRNA mills. These mills will dilute out the stellar, independent CRNA that takes care of ASA 4 patients with a CRNA pool consisting of every nurse and their mother who thinks its an easy way to make a buck. I do not think all of these people will be on par with anesthesiologists.

And as a final aside, I have to say these arguments about knowledge that are based on "reading books" are viewed with extreme disdain in the physician community. Most medical students are book smart. That is how they were able to gain acceptance into medical school. Every physician remembers the medical student who could ace the SAT, MCAT, USMLE, but who just seemed clueless in a clinical context. Real knowledge is experiential combined with theory. Therefore, if you want make an argument about knowledge that a physician is receptive too, make it based on case experience too, not just based on what books you read. The latter argument will get you laughed at.

Happy Thanksgiving, everyone.






I believe the spectrum of care in the critically ill patient begins prehospital and continues until discharge. Our role as CRNAs varies by facility and practice model, but typically deals w/preoperative assessment and optimization, followed by the operative and postanesthetic periods. It isn't that we are incapable of managing ICU patients or lack the education to do so, but our role is centered around the operative suite. The care provided outside of that environment is something that we learn by clinical practice and education before we are accepted into a CRNA program. Once we cross over into advanced practice we are no longer expected to manage patients in the ICU.

To answer your questions:
1) I probably could run an ICU, but not well. The majority of CNRAs on this site have worked in different ICUs for many years, supervising the staff and managing patients as charge nurses. They have much more ICU experience than I do and could undoubtedly do a much better job of it. For them, the ICU is as much (or more) of a familiar environment than the OR and are intimately familiar w/orders, protocols, management, and interventions in the ICU patient population.
2) Yes, I think physicians are necessary in the ICU. There is no nursing equivalent to an intensivist to follow patients and manage their care, however a critical care CNS would probably do very well in that evironment.
3) Reading a textbook doesn't confer the same degree of judgement, however understanding the material contained within it confers the same degree of knowledge of that text. A typical CRNA's judgement comes from applying that knowledge to their years of experience in the nursing management of critically ill patients just as you likely applied that knowledge to your patient experiences. Since your experiences are different than a CRNA's your view may be different in regards to patient management but your judgement may not be all that dissimilar, nor will the interventions you chose.
4) Without having done your job, it would be as difficult for me to make an accurate assessment of you as it would for you to do the same in regards to my position.

Welcome to the site. Hopefully we can gain some insight into one anothers' views and have some interesting dialogues.

[Anthony]

And as a final aside, I have to say these arguments about knowledge that are based on "reading books" are viewed with extreme disdain in the physician community. Most medical students are book smart. That is how they were able to gain acceptance into medical school. Every physician remembers the medical student who could ace the SAT, MCAT, USMLE, but who just seemed clueless in a clinical context. Real knowledge is experiential combined with theory. Therefore, if you want make an argument about knowledge that a physician is receptive too, make it based on case experience too, not just based on what books you read. The latter argument will get you laughed at.

Happy Thanksgiving, everyone.

My sentiments exactly....

[ethernaut]

I am sensing a lot of "Good Will Hunting" sentiment on the board with regards to self-directed learning, which is fantastic and should always be encouraged. That said, there is also the saying that "he who teaches himself has a fool for a master." Medicine (and nursing) has changed a lot in the last 100 years, not the least of which is regulatory oversight from a variety of angles. Certainly government regulation, but more important is the professional oversight provided by your peers. An organization of nurses is best qualified to dictate what constitutes good nursing care, just as physicians are responsible for dictating what constitutes good medical care. Yes, there is an aspect of "the fox guarding the chicken coop," but the alternatives (non-health care administrative types dictating medical practice) are equally wrought with problems. That battle is a major source of strife for current and aspiring doctors.

A little tangential, but to get back on track, I think Anesthesiologist's point is that self-directed learning is a small piece of the puzzle. You can read a surgery book and in your mind have mastered the concepts, but with no frame of reference your knowledge is markedly limited. "You don't know what you don't know," so to speak. Every once in awhile this comes up when someone botches a plastic surgery job in their garage and it makes the headline news.

The point is, I can't just read a book and become an anesthesiologist. I will have to sit for written and oral boards and receive approval from my future colleagues prior to being qualified to practice. I presume (and my question is), that there must be a similar sort of process prior to working as a CRNA.

Personally, I think it would be an interesting experiment to have MDs sit for CRNA boards (or equivalent) and vice versa, but there is no way in Hades that the ASA or the AANA would support such an experiment. Both sides would have far too much to lose depending on the outcome :)

thanks for coming aboard with good discussions, along with your cohort, anesthesiologist. i think your perspective here is refreshing, and answers some questions that many have had along the way. and i hope you continue to stay involved here during your CA tenure. that being said, i would just like to comment that although you have relevant opinions about the nurse-doc debates (along the whole gamut), i have to say that i think you might be a little green when it comes to your feelings about CRNAs. please don't take this the wrong way. i only say this because i've seen many PGY-1s come thru CA years, and their opinions and voices and contexts all seem to turn from the way you speak "to us" now.

now, i can't speak for everyone, but only for myself, when i say that there's an "apparent" thought-process teaching that happens in the hallowed halls of my alma mater's anesthesia education realm. it seems the "good" docs all turn 180 degrees by CA3/graduation. very anti-CRNA in my opinion. my place could be the minority, but i'm willing to bet otherwise.

why do i say this to you? i suppose just to let you know that CRNAs really don't dislike docs. and we're not really out there to "take" your jobs, or whatever else 'excuse' that gets labeled along the way. when you get to where you're going, try to remember the dialogues here on N-A.org, and see how your feelings are/were/have changed. i'd be really curious. perhaps, you could be the future of your profession that actually promotes breaking down these "unnecessary walls". just my opinions by the way.

thanks again to you and anesthesiologist (and mil) (and jet *crickets*) for being here.

[BlackMAGIC]

DITTO....this young grasshopper is learning alot from everyone in this thread. Thank you all

[AnesRes2014]

thanks for coming aboard with good discussions, along with your cohort, anesthesiologist. i think your perspective here is refreshing, and answers some questions that many have had along the way. and i hope you continue to stay involved here during your CA tenure. that being said, i would just like to comment that although you have relevant opinions about the nurse-doc debates (along the whole gamut), i have to say that i think you might be a little green when it comes to your feelings about CRNAs. please don't take this the wrong way. i only say this because i've seen many PGY-1s come thru CA years, and their opinions and voices and contexts all seem to turn from the way you speak "to us" now.

now, i can't speak for everyone, but only for myself, when i say that there's an "apparent" thought-process teaching that happens in the hallowed halls of my alma mater's anesthesia education realm. it seems the "good" docs all turn 180 degrees by CA3/graduation. very anti-CRNA in my opinion. my place could be the minority, but i'm willing to bet otherwise.

why do i say this to you? i suppose just to let you know that CRNAs really don't dislike docs. and we're not really out there to "take" your jobs, or whatever else 'excuse' that gets labeled along the way. when you get to where you're going, try to remember the dialogues here on N-A.org, and see how your feelings are/were/have changed. i'd be really curious. perhaps, you could be the future of your profession that actually promotes breaking down these "unnecessary walls". just my opinions by the way.

thanks again to you and anesthesiologist (and mil) (and jet *crickets*) for being here.

I certainly will, and overall I've been rather impressed by how I've been received. Likewise, part of my reasoning in coming here was similarly to let you know that physicians don't inherently dislike CRNAs, either. I think it is human nature to dislike/fear what you don't understand, so if we can break down even a few doors to understanding, we will have accomplished something.

Regardless of how my professional opinions towards leadership (on both sides of the aisle) develop, it will certainly not affect how I interact with individuals on a personal level. I think by the time you enter medicine, your interpersonal skills are more or less developed. Basically, there is no excuse for creating a disrespectful or hostile work environment.

[ethernaut]

Regardless of how my professional opinions towards leadership (on both sides of the aisle) develop, it will certainly not affect how I interact with individuals on a personal level.

long live the inherent epitaph ;)

[bettermj]

BTW,

Personally, folks should be called what they like. I don't use the term if someone doesn't like it. And, I hate the insurance industry :).

call me T-bone

[MmacFN]

:clap2:

awesome.


I certainly will, and overall I've been rather impressed by how I've been received. Likewise, part of my reasoning in coming here was similarly to let you know that physicians don't inherently dislike CRNAs, either. I think it is human nature to dislike/fear what you don't understand, so if we can break down even a few doors to understanding, we will have accomplished something.

Regardless of how my professional opinions towards leadership (on both sides of the aisle) develop, it will certainly not affect how I interact with individuals on a personal level. I think by the time you enter medicine, your interpersonal skills are more or less developed. Basically, there is no excuse for creating a disrespectful or hostile work environment.

[MugsyMD]

I would venture to say (and I can only speak from MY experience) that a first year intern has NO WHERE CLOSE to the same experience as an RN working in a high acuity ICU.

Two comments in response to this statement: First, I think you are grossly overstating the value of “ICU experience”. Working in an ICU is not the same thing as being a resident or attending physician charged with the responsibility of directing treatment for ICU patients. I know this because as an anesthesiology resident I spent a of a lot of time rotating through the hospital’s ICU.

Second: Whatever head-start in experience you get from a year of working in an ICU, an anesthesiology resident will rapidly overtake you. Remember, working somewhere where you are receiving formal training from an attending is a far more intense learning experience than simply working there. And again, anesthesiology residents are armed with far more medical knowledge, and this too makes a big difference in the rate at which they learn.


I worked in a Level 1 SICU/Trauma unit for quite a few years, when we had an intern to call, we knew that we'd be calling the shots when it came to managing the patient.
Obviously, I don’t know what took place in your hospital, but I’ve had four different ICU experiences: medical school, anesthesiology residency, cardiac fellowship, and current hospital where I’m on staff, and all of them were staffed by residents and attendings. None of these hospitals had first-year anesthesiology residents handling ICU patients.


But I worked in a place where if you weren't a good enough RN, you'd get fired. Perhaps it's not that way everywhere. Nursing school isn't very hard in my opinion. There are plenty of people who made it through nursing school and I hope they never take care of me. However, once you decide to become an ICU nurse, there is an entire different game to be played. My ICU training included a 12 week ICU course (computer based and interactive), as well as 3-6 months with a preceptor. And THEN you'd get easier patients....it's not until after your first 1-1.5 years that you'd get sick patients on your own.

I don’t think that anyone would deny that ICU nurses have to be a bit better than the standard RN, but that doesn’t put them on par in terms of knowledge with a newly-minted MD. We enter the “anesthesia” scene with a far more solid foundation in medicine. You should never underestimate the importance of that fact!

[MugsyMD]

I believe that as an experienced ICU nurse you are held to a similar ( not exactly the same standard) as an intern. Pt has problems identify and make corrections and hold the fort until the MD shows up, as for the non acute decisions sure all of the time, the real difference IMHO is ownership, as an ICU nurse you learn there is someone to make a final decision unlike an intern or resident and this mindset is the hardest thing to unlearn.

Funny.....in every hospital where I’ve worked, there was always an MD present in the ICU. The RNs never had to “hold down the fort”.

[MugsyMD]

I believe that as an experienced ICU nurse you are held to a similar ( not exactly the same standard) as an intern. Pt has problems identify and make corrections and hold the fort until the MD shows up, as for the non acute decisions sure all of the time, the real difference IMHO is ownership, as an ICU nurse you learn there is someone to make a final decision unlike an intern or resident and this mindset is the hardest thing to unlearn.

Stanman, you bring up an excellent point.

The anesthesiology resident is being taught in a manner that allows him or her to take ownership of the patients. That is the ultimate purpose of an anesthesiologist’s training, and the day-to-day experiences of the resident’s training reflects that goal.

A CRNA is not taught that way (I know this because I work with CRNA students). When I am overseeing them, I teach them the technical aspects of anesthesiology. I am not going to spend my time covering in-depth topics like physiology or pharmacology with them. I train them to competently deliver general anesthesia to ASA 1’s and 2’s. With my residents, I am training them to do exactly what I do. Big difference there.

[armygas]

Stanman, you bring up an excellent point.

The anesthesiology resident is being taught in a manner that allows him or her to take ownership of the patients. That is the ultimate purpose of an anesthesiologist’s training, and the day-to-day experiences of the resident’s training reflects that goal.

A CRNA is not taught that way (I know this because I work with CRNA students). When I am overseeing them, I teach them the technical aspects of anesthesiology. I am not going to spend my time covering in-depth topics like physiology or pharmacology with them. I train them to competently deliver general anesthesia to ASA 1’s and 2’s. With my residents, I am training them to do exactly what I do. Big difference there.

You do not work (obviously) with military students......

[RAYMAN]

Funny.....in every hospital where I’ve worked, there was always an MD present in the ICU. The RNs never had to “hold down the fort”.

Funny, in the CVICU I worked there was never a MD present, so I had to "hold down the fort". Our medical director, a CV surgeon, said we had the knowledge base of a second year surgical resident...guess that doesn't count for anything since you obviously know everything. In fact, when a patient arrested, we ran the code...NO other MD was allowed to make decisions in our unit other than our CV surgeons. I guess you would get your feelings hurt there...

[deepz]

Stanman, you bring up an excellent point.

The anesthesiology resident is being taught in a manner that allows him or her to take ownership of the patients. That is the ultimate purpose of an anesthesiologist’s training, and the day-to-day experiences of the resident’s training reflects that goal..........

Ho-LEE-F**K. Where does one start.....?

[deepz]

You do not work (obviously) with military students......

Sounds like some A$Ahole from Georgia. Keep them SRNAs dumbed-down, down on the plantation.

[Esper]

A CRNA is not taught that way (I know this because I work with CRNA students). When I am overseeing them, I teach them the technical aspects of anesthesiology. I am not going to spend my time covering in-depth topics like physiology or pharmacology with them. I train them to competently deliver general anesthesia to ASA 1’s and 2’s. With my residents, I am training them to do exactly what I do. Big difference there.

You certainly aren't a preceptor for my school either as my PD has already stated they wouldn't stand for this. If you are going to be restrictive, then just stop teaching all together. Your services are not required.

[ADMIN]

MugsyMD AKA BillyGoatGruff AKA DrSandman is a resident who is absolutely and totally clueless as to what CRNAs do, our capabilities or our educational process. He is a perfect example of the type or moronic individual who's attitude is the main cause for 'militant' CRNAs as well as those who quit ACT practices to go independent. It is attitudes like his which contrary to what is said on SDN, directly result in the animosity between CRNAs and MDs. He has been banned, his ip banned and his email and IP (which I tracked) submitted to stopforumspam.com which is a national service that gives this information to every forum website who subscribes.

Mr Resident, if you think you have better outcomes, do better anesthesia and are smarter than any CRNA then stop bitching and COMPETE in the market with us. Otherwise shut your trap and stop bothering to try and post your BS on MY website. Stick to SDN.

This individual only makes me more thankful for MilMD, AnesRes2014 and Anesthesiologist

[Anthony]

To all viewing this thread......We are making an honest effort to ensure a productive exchange. Revisiting the same old diatribe only ensures continued animosity and polarizing views. Let's move forward folks.

[Anesthesiologist]

To all viewing this thread......We are making an honest effort to ensure a productive exchange. Revisiting the same old diatribe only ensures continued animosity and polarizing views. Let's move forward folks.

I agree. There are great people on both sides. There are open-minded people on both sides. The old diatribe is well-worn. Let's try something new.

[yoga]

I will post this as much as I can. The new paradigm in healthcare is going to be based almost solely on economics. Like it or not, argue it from any direction you want, this is the future.

[armygas]

The bottom line is this..... Anesthesiologists earn their higher income for their utility outside of the perioperative period.... But in that 72 hour window there is absolutely no difference in what a CRNA or an Anesthesiologist brings to the table. That is the reality.

[armygas]

I will post this as much as I can. The new paradigm in healthcare is going to be based almost solely on economics. Like it or not, argue it from any direction you want, this is the future.

Yes.... Yes it is.

[EMTRNBSN]

I will post this as much as I can. The new paradigm in healthcare is going to be based almost solely on economics. Like it or not, argue it from any direction you want, this is the future.

which is EXACTLY why, IMHO, allowing CRNA "education" programs to take a bunch of one-year wonders and churn out a bunch of know nothing stool monkey tube jockeys may ultimately inflict severe damage on the CRNA profession...

Anesthesiologists are not the only ones who will be called into account to justify their value...

[Anesthesiologist]

which is EXACTLY why, IMHO, allowing CRNA "education" programs to take a bunch of one-year wonders and churn out a bunch of know nothing stool monkey tube jockeys may ultimately inflict severe damage on the CRNA profession...

Anesthesiologists are not the only ones who will be called into account to justify their value...

100% Agreed! Please see my response to Yoga's other post.

[stanman1968]

there was an md ON the floor? 24/7? really?

[J-Dubya]

there was an md ON the floor? 24/7? really?

Seems pretty unlikely and unnecessary.

In my old ICU, here in little old Boston, the whole CT service (and we were busy with sick patients) was run by PAs. Might see the surgeon once a day, but not always..... :)

[LouisiAnimal]

Seems pretty unlikely and unnecessary.

In my old ICU, here in little old Boston, the whole CT service (and we were busy with sick patients) was run by PAs. Might see the surgeon once a day, but not always..... :)

In my old ICU they had an intensivist physically in the house 24/7. It's 4 of them and they worked 12 hr shifts, 2 weeks on, 2 weeks off. Maybe this is the kinda unit he's referring to

[AnesRes2014]

In the SICU where I'm working now, the only physician in-house overnight is the intern. There's also a fellow/attending on-call, and of course the surgeons are on-call, also.

[snaggletooth]

In the SICU where I'm working now, the only physician in-house overnight is the intern. There's also a fellow/attending on-call, and of course the surgeons are on-call, also.

This is similar to my med/surg ICU experience. Interns in house 24/7, Fellow variably available, Intensivist on-call

[Vents-n-gtts]

At night we have an R2 on call (always surgery, never an anesthesia resident). Infrequently (more so recently, because we have a shortage of residents!) we have an intern who is usually also covering the floor and the team specific patients coming through the ER. We always have a fellow an attending on call. Intensivists/critical care/pulmonary/anestehsia doctors are active consultants of the team during the day, but at night they are not on call or available.

Question for the anesthesia resident: you all have to rotate through an ICU right? Is it common for you guys to hate it? I work in a really busy ICU, so I understand how someone could be frustrated/tired/overwhelmed of working there for a month on a 6 on 1 off schedule, but hating it is another thing (independent of nursing staff usually). It is common knowledge that residents hate rotating through my unit, especially anesthesia residents but I never understood why. I would think that in residency, outside of your OR time, the ICU would be the next best thing?

[snaggletooth]

Question for the anesthesia resident: you all have to rotate through an ICU right? Is it common for you guys to hate it? I work in a really busy ICU, so I understand how someone could be frustrated/tired/overwhelmed of working there for a month on a 6 on 1 off schedule, but hating it is another thing (independent of nursing staff usually). It is common knowledge that residents hate rotating through my unit, especially anesthesia residents but I never understood why. I would think that in residency, outside of your OR time, the ICU would be the next best thing?Interesting question. Most residents hated coming through our ICU too; they hated the long hours and how sick the patients were. I think it was mostly residents who were headed for family practice, OB, or such. I don't recall the anesthesia residents minding the ICU--except one in particular who did not belong at the bedside whatsoever--what a trip, but that's another story

[Vents-n-gtts]

Oh wow OB rotates through your ICU! We only have surgery and anesthesia residents come thorugh, unless we have an OB/GYN patient that is critically unstable then we get to see the OB/GYN team but only for that patient. I guess my unit is considered a close unit? bo!

[AnesRes2014]

Question for the anesthesia resident: you all have to rotate through an ICU right? Is it common for you guys to hate it? I work in a really busy ICU, so I understand how someone could be frustrated/tired/overwhelmed of working there for a month on a 6 on 1 off schedule, but hating it is another thing (independent of nursing staff usually). It is common knowledge that residents hate rotating through my unit, especially anesthesia residents but I never understood why. I would think that in residency, outside of your OR time, the ICU would be the next best thing?

I actually do kind of enjoy it. Moreso with the q3 schedule we had before we went down to 2 residents for the holidays. 8 straight days of 12+hr shifts is going to get a little old.

I think I especially enjoy it having just come off a general surgery rotation where it was mostly floor scut work and very little learning. There is a ton of teaching/learning going on in the ICU, and I feel like my diagnostic/therapeutic skills have markedly improved. Plus, I much prefer taking care of 8-12 sick patients vs 30-odd occasionally-sick/not-so-sick patients.

[Vents-n-gtts]

Mine is a 24 bed ICU and there is always something going on. I feel like last year we had more R2s that were discontent with the rotation, they said it was good experience but they missed the OR and did not feel like they were really learning anything they needed to know. That I found odd because line insertion, assisting in intubation (usually we have anesthesia team captain intubate)/and occasional intubation with critical care attending, managing very sick patients would be knowledge you can use in the OR. Thanks for answering...

[AnesRes2014]

Mine is a 24 bed ICU and there is always something going on. I feel like last year we had more R2s that were discontent with the rotation, they said it was good experience but they missed the OR and did not feel like they were really learning anything they needed to know. That I found odd because line insertion, assisting in intubation (usually we have anesthesia team captain intubate)/and occasional intubation with critical care attending, managing very sick patients would be knowledge you can use in the OR. Thanks for answering...

I'm sure it's related to their year. There's a CA-1 as one of the other 2 residents, and he seems less excited than I to be there, I presume because he misses the OR. But for me, this is as good as it gets (more or less) this year.

[JadamR15]

AnesRes,

When the ASA/ABA changed its residency from three to four years, did residents still complete a transitional/medicine/surgery year?

[ajefferson]

At night we have an R2 on call (always surgery, never an anesthesia resident). Infrequently (more so recently, because we have a shortage of residents!) we have an intern who is usually also covering the floor and the team specific patients coming through the ER. We always have a fellow an attending on call. Intensivists/critical care/pulmonary/anestehsia doctors are active consultants of the team during the day, but at night they are not on call or available.

Question for the anesthesia resident: you all have to rotate through an ICU right? Is it common for you guys to hate it? I work in a really busy ICU, so I understand how someone could be frustrated/tired/overwhelmed of working there for a month on a 6 on 1 off schedule, but hating it is another thing (independent of nursing staff usually). It is common knowledge that residents hate rotating through my unit, especially anesthesia residents but I never understood why. I would think that in residency, outside of your OR time, the ICU would be the next best thing?

I frequently ask our residents if they're excited about being there/leaving the ICU. We have neurology, neurosurgery, and anesthesiology residents on a q3 schedule. More often the neurology and anes residents enjoy the work but not the schedule. Nsurg residents "can't wait to get back to the OR," almost without fail.

[AnesRes2014]

AnesRes,

When the ASA/ABA changed its residency from three to four years, did residents still complete a transitional/medicine/surgery year?

There are still 3 clinical anesthesia years, plus an internship. Categorical programs have the intern year built-in, advanced programs require you to find an internship on your own. Some programs (UVA comes to mind) will get fancy and do a half-year of clinical anesthesia during PGY1 (post-graduate year). Of course, then they're doing a half-year of intern-y stuff when everyone else in the country is in the OR during PGY2.

[JadamR15]

Ah, so no intern year prior to 1989 or so?

[AnesRes2014]

Ah, so no intern year prior to 1989 or so?

No, I think they still had to do an intern year, you just had to do it separate from your anesthesia residency. There are still some residency programs with that model, such as radiology. There aren't any integrated radiology programs out there that I'm aware of.

[AnesRes2014]

Just thought I'd check back in with the majority of my CA-1 year done and offer the opportunity to ask questions about my experiences if anyone is curious (otherwise it'd just be a rambling expose (accent over the "e", it's not Friday night...yet)). This year I've done gen surg, ortho, urology, gyn, OB, acute pain, ENT. Next year is specialties: peds, cardiac, neuro, vascular, thoracic, chronic pain, more ICU months. Fire away, if you're so inclined.

[MmacFN]

Hey man!

Welcome back!!

So tell us how was it? Do you love it! Are you enjoying the skills and the constant use of your knowledge?

Whats the best thing so far and what has been the worst?

Im stoked yer almost done year 1!!



Just thought I'd check back in with the majority of my CA-1 year done and offer the opportunity to ask questions about my experiences if anyone is curious (otherwise it'd just be a rambling expose (accent over the "e", it's not Friday night...yet)). This year I've done gen surg, ortho, urology, gyn, OB, acute pain, ENT. Next year is specialties: peds, cardiac, neuro, vascular, thoracic, chronic pain, more ICU months. Fire away, if you're so inclined.

[AnesRes2014]

It is, uh, AWESOME! Definitely a brilliant decision on my part.

I'd say the worst part are the attendings that make a huge deal out of doing X because they always do Y. It's one thing if they're just like, "OK, here's another way to do it, this is why it might be better or worse," but sometimes it's like the end of the world despite the fact that half of their colleagues do it a different way every day of their life. But that's how medicine's always been, in my limited experience. It's just magnified in a more procedural specialty.

The best part is taking a super sick patient through a long surgery and making it look easy. Granted, it might not happen as often as I'd like it to, but it still feels pretty good...

Overall, this year has been great. Next year will be a little rougher, but in a way I'm looking forward to the challenge.


Hey man!

Welcome back!!

So tell us how was it? Do you love it! Are you enjoying the skills and the constant use of your knowledge?

Whats the best thing so far and what has been the worst?

Im stoked yer almost done year 1!!

[MmacFN]

hehehe

yah like learning to tape the tube "the only right way" differently everytime? hehehe

Im excited for you! Sounds like it is all you had hoped and Im glad to hear it! Cant wait to hear more!



It is, uh, AWESOME! Definitely a brilliant decision on my part.

I'd say the worst part are the attendings that make a huge deal out of doing X because they always do Y. It's one thing if they're just like, "OK, here's another way to do it, this is why it might be better or worse," but sometimes it's like the end of the world despite the fact that half of their colleagues do it a different way every day of their life. But that's how medicine's always been, in my limited experience. It's just magnified in a more procedural specialty.

The best part is taking a super sick patient through a long surgery and making it look easy. Granted, it might not happen as often as I'd like it to, but it still feels pretty good...

Overall, this year has been great. Next year will be a little rougher, but in a way I'm looking forward to the challenge.

[ABCRn]

A favorite doc who rotated through our ICU (now a resident like you) told us a month ago while visiting the unit how one of the docs he was training with berated him for not doing a 'through and pull back' stick when placing art lines. (This is someone who was good, fast, kind to the patient AND always sutured his art lines in place.) Different strokes for different folks....Enjoying your posts!

[AnesRes2014]

A favorite doc who rotated through our ICU (now a resident like you) told us a month ago while visiting the unit how one of the docs he was training with berated him for not doing a 'through and pull back' stick when placing art lines. (This is someone who was good, fast, kind to the patient AND always sutured his art lines in place.) Different strokes for different folks....Enjoying your posts!

Yep, that's another one. Personally, I only do the through-and-through if I can't thread the wire or get a not-so-convincing flash the first time. Why make 2 holes when you don't have to? That said, I use it a not insignificant amount of the time since A) lots of patients with tiny arteries and B) I'm not the most proficient at centering up the artery. It happened one time when we had a medical student in the room, and I told her "watch this," and explained what I was going to do to salvage it. The attending gave me the stink-eye for some reason and started to say something to me about my decision to go through-and-through when (thankfully) I got flow, re-threaded the wire, and slid the catheter over it. Always a good feeling. Of course, if I missed I would have looked like a chump.

Overall, a-lines are probably the most humbling thing I've encountered in residency. I've probably only done 15-20 central lines (we get a lot next year) but I can already safely say I'm more comfortable with them than a-lines at this point.

[dontquit]

I have thoroughly enjoyed this thread. I thank the physicians for giving us all insight into their thoughts and ideas on anesthesia training and its application. I also thank the CRNA's and students who have posted their insight and questions.

With that said, I still wonder what it all means at the end of the day. I have been in practice for 9 years now. I have worked at the largest of medical centers (Mayo) and the smallest in rural podunk Wisconsin and Iowa. I have seen the worst of CRNA's (Couldn't recognize a total spinal and the nurses were holding the patient's head up all night at the bedside, couldn't interpret results of Echo, EKG, Stress test and put them into practical sense...hell for that matter couldn't apply any test on patients to practice) I have also observed the worst of Anesthesiologists (Didn't know how to check out a machine, took the patient to pacu with a sat of 58% on room air and didn't think this was a problem...etc)

I believe we all have alot to offer the medical community! We both deliver excellent anesthesia. The argument that because of the advances of monitors and drugs, anyone can do a safe anesthetic is just pure bull crap! There is an art to anesthesia. It has evolved since the days of drop ether and palpating pulses to now monitoring BIS, respiratory variation in the arterial waveform, etc. Patients are sicker. ASA III and IV are now the norm, not the exception.

Reading through this I see anesthesiologist and AnesRes posting that Pre and post operative is where the rubber meets the road. Having worked with many...MANY anesthesiologists. I can honestly say...without malice...this is not at all true. The ones that I have had the pleasure of working with absolutely did not manage the patients in ICU. I have noticed no difference in judgement preoperatively on when patients can/should go to the OR. I haven't observed the awe inspiring choices in anesthetic and the miracles intraoperatively that have made me think...DAMN...that is why anesthesiologists are the gold standard in anesthesia. What I have observed is two groups of medical professionals, both very well trained, taking excellent care of their patients, and setting the bar high for those in the future.

What I think will be necessary for the future of anesthesia, is to come to a collaborative agreement between the two groups on a model that will be beneficial for both.

[AnesRes2014]

I have thoroughly enjoyed this thread. I thank the physicians for giving us all insight into their thoughts and ideas on anesthesia training and its application. I also thank the CRNA's and students who have posted their insight and questions.

With that said, I still wonder what it all means at the end of the day. I have been in practice for 9 years now. I have worked at the largest of medical centers (Mayo) and the smallest in rural podunk Wisconsin and Iowa. I have seen the worst of CRNA's (Couldn't recognize a total spinal and the nurses were holding the patient's head up all night at the bedside, couldn't interpret results of Echo, EKG, Stress test and put them into practical sense...hell for that matter couldn't apply any test on patients to practice) I have also observed the worst of Anesthesiologists (Didn't know how to check out a machine, took the patient to pacu with a sat of 58% on room air and didn't think this was a problem...etc)

I believe we all have alot to offer the medical community! We both deliver excellent anesthesia. The argument that because of the advances of monitors and drugs, anyone can do a safe anesthetic is just pure bull crap! There is an art to anesthesia. It has evolved since the days of drop ether and palpating pulses to now monitoring BIS, respiratory variation in the arterial waveform, etc. Patients are sicker. ASA III and IV are now the norm, not the exception.

Reading through this I see anesthesiologist and AnesRes posting that Pre and post operative is where the rubber meets the road. Having worked with many...MANY anesthesiologists. I can honestly say...without malice...this is not at all true. The ones that I have had the pleasure of working with absolutely did not manage the patients in ICU. I have noticed no difference in judgement preoperatively on when patients can/should go to the OR. I haven't observed the awe inspiring choices in anesthetic and the miracles intraoperatively that have made me think...DAMN...that is why anesthesiologists are the gold standard in anesthesia. What I have observed is two groups of medical professionals, both very well trained, taking excellent care of their patients, and setting the bar high for those in the future.

What I think will be necessary for the future of anesthesia, is to come to a collaborative agreement between the two groups on a model that will be beneficial for both.

Like virtually every other medical specialty, I feel like the future of physician anesthesiology likes in specialization (i.e. fellowships). Particularly critical care, cardiothoracic, peds, and pain. Not sure how useful women's or neuro is outside of academic centers, and regional I think just depends on how much training you got in residency.

[JoshSRNA]

I have thoroughly enjoyed this thread. I thank the physicians for giving us all insight into their thoughts and ideas on anesthesia training and its application. I also thank the CRNA's and students who have posted their insight and questions.

With that said, I still wonder what it all means at the end of the day. I have been in practice for 9 years now. I have worked at the largest of medical centers (Mayo) and the smallest in rural podunk Wisconsin and Iowa. I have seen the worst of CRNA's (Couldn't recognize a total spinal and the nurses were holding the patient's head up all night at the bedside, couldn't interpret results of Echo, EKG, Stress test and put them into practical sense...hell for that matter couldn't apply any test on patients to practice) I have also observed the worst of Anesthesiologists (Didn't know how to check out a machine, took the patient to pacu with a sat of 58% on room air and didn't think this was a problem...etc)

I believe we all have alot to offer the medical community! We both deliver excellent anesthesia. The argument that because of the advances of monitors and drugs, anyone can do a safe anesthetic is just pure bull crap! There is an art to anesthesia. It has evolved since the days of drop ether and palpating pulses to now monitoring BIS, respiratory variation in the arterial waveform, etc. Patients are sicker. ASA III and IV are now the norm, not the exception.

Reading through this I see anesthesiologist and AnesRes posting that Pre and post operative is where the rubber meets the road. Having worked with many...MANY anesthesiologists. I can honestly say...without malice...this is not at all true. The ones that I have had the pleasure of working with absolutely did not manage the patients in ICU. I have noticed no difference in judgement preoperatively on when patients can/should go to the OR. I haven't observed the awe inspiring choices in anesthetic and the miracles intraoperatively that have made me think...DAMN...that is why anesthesiologists are the gold standard in anesthesia. What I have observed is two groups of medical professionals, both very well trained, taking excellent care of their patients, and setting the bar high for those in the future.

What I think will be necessary for the future of anesthesia, is to come to a collaborative agreement between the two groups on a model that will be beneficial for both.

Excellent post!

[J-Dubya]

Like virtually every other medical specialty, I feel like the future of physician anesthesiology likes in specialization (i.e. fellowships). Particularly critical care, cardiothoracic, peds, and pain. Not sure how useful women's or neuro is outside of academic centers, and regional I think just depends on how much training you got in residency.


Out of the 10 residents I know that are finishing up this year (at a local program where I work sometimes), 9 are going on to do fellowships.

[ethernaut]

hey anesres2014,

just wondering.. i notice in few places (around me, anyways), it's the anesthesiologist that runs (OR) departments, oversees surgicenters, etc... do residents get any kind of (formal/informal) education, about the business side of anesthesia, during their post-medical school training? or would people 'investigate' on their own time, such as MBA, or merely on-the-job training?

i can clearly say that my education about things like billing, CMS, and administrative realms (during anesthesia training) was quite anemic in the grand scheme of things. i'm only four year out of school, but i still feel i'm playing catch-up.

thanks-
dino

[AnesRes2014]

At least 2 of the top admin anesthesiologists at my institution have MBAs, same as at my medical school. I suspect a lot of the bigger departments have a couple MBAs in the upper ranks. For most of the rank-and-file it's mostly OTJ training. We get a couple lectures a year on billing and administrative issues, mostly to prepare the CA3s/fellows for the real world, so to speak. That said, I don't think anyone feels totally prepared once they graduate.

It's a problem throughout medical specialties, and part of the reason so many private practices are giving way to hospital-based practices. As one of our MBAs said, with the time you would spend doing billing, payroll, and other administrative tasks, you can hire someone for less who'll do it better and faster, so it's kind of a no-brainer.


hey anesres2014,

just wondering.. i notice in few places (around me, anyways), it's the anesthesiologist that runs (OR) departments, oversees surgicenters, etc... do residents get any kind of (formal/informal) education, about the business side of anesthesia, during their post-medical school training? or would people 'investigate' on their own time, such as MBA, or merely on-the-job training?

i can clearly say that my education about things like billing, CMS, and administrative realms (during anesthesia training) was quite anemic in the grand scheme of things. i'm only four year out of school, but i still feel i'm playing catch-up.

thanks-
dino

[bettermj]

I was discussing the MBA with my coworker yesterday. I got mine in 2003. When we were discussing some business venture I was looking into, he said, "Man you should know the answer to that question, you have your MBA."

Well, I laughed and my best response I could think of was, "Having your MBA is like going to anesthesia school and taking all of your classes and acing all the tests, yet never having to go to clinicals."

In reality, that's what it's like. It is great to have. But really, the only thing it's helped me do, so far, is land job interviews.

[MmacFN]

Exactly how my buddy with an MBA describes it.

I personally do not see the utility of an MBA in our profession even as it might relate to the business of anesthesia. It is a totally different animal.


I was discussing the MBA with my coworker yesterday. I got mine in 2003. When we were discussing some business venture I was looking into, he said, "Man you should know the answer to that question, you have your MBA."

Well, I laughed and my best response I could think of was, "Having your MBA is like going to anesthesia school and taking all of your classes and acing all the tests, yet never having to go to clinicals."

In reality, that's what it's like. It is great to have. But really, the only thing it's helped me do, so far, is land job interviews.

[ethernaut]

Exactly how my buddy with an MBA describes it.

I personally do not see the utility of an MBA in our profession even as it might relate to the business of anesthesia. It is a totally different animal.

so how should students (and CRNAs) be further educated on such matters of the business side of anesthesia? I'm sure jan has many better things to do than lecture at most every college.

[MmacFN]

Thats the rub.

To date the only way people have learned about the business of anesthesia has been OTJ.

Lectures are nice but the fact is you cannot even begin to understand anesthesia billing in a few hours. It has taken me 4 years to really get a grasp on the business of anesthesia and I have had a number of excellent mentors (Juan, Jan, Jay). Even after all that I still make mistakes and have alot more to learn.

There has been a push to have a real business of anesthesia seminars and to date there has been something like that which was held before the MYA. However, even that isnt enough. Some discussion has occurred about having a class in anesthesia programs on it but frankly, i doubt students who are worried about just passing will take anything from it.

Frankly, to keep it all straight and really learn it, like everything else, you have to DO it. However, the fact is most anesthesia grps contract out billing to other companies who change ~6% to bill for you.

As for the other parts of the business such as starting a grp, bidding on an RFP, writing a contract etc.. that is found in Jans book and we will see more of this in future publications.

When i asked my MBA buddy about all these things he really could only give me generalities since every business is so completely different. That is where networking comes in. Goto meetings, get to know the people who are doing it and ask their advice. My experience has been that CRNAs who have been successful at it are more than happy to teach you and guide you as you do it yourself.


so how should students (and CRNAs) be further educated on such matters of the business side of anesthesia? I'm sure jan has many better things to do than lecture at most every college.

[Esper]

BetterMJ clean up your PMs, if ya don't mind. I can't send ya one because you've exceeded you limit. Gotta question about MBA.

[bettermj]

BetterMJ clean up your PMs, if ya don't mind. I can't send ya one because you've exceeded you limit. Gotta question about MBA.

Ok..... Working on it.

To add, The MBA I earned was a lot of fun. It was applicable to just about any business. Learning accounting, economics, HR, finances, and marketing is all very applicable to our industry.

Yet still, unless you are actively doing all the stuff in your own business or career, it's all didactic. Very rewarding on a personal level, and potentially for your career. But again, unless you've actually done anesthesia, don't believe in yourself that you can put me to sleep until you've done your clinicals.... No matter how well you do on your tests. (make sense?). Same rules for business.

I would still recommend one If you're interested. Find one that is entrepreneurial based if possible. Those tend to teach you the nuts and bolts, versus all the intricate theories that you won't need. It's like taking the nursing theory out of anesthesia school and putting in Anesthesia Machines 101.

And I DEF would not take out ANY student loans to pay for ANY MBA program, ever.


Eta: the second and remaining paragraphs are meant for the general people reading, not directed just for Esper.






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[propoFool]

BetterMJ clean up your PMs, if ya don't mind. I can't send ya one because you've exceeded you limit. Gotta question about MBA.
+1

[bettermj]

+1

I sent you a message.

You have my cell.... Text me if you want. :)


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[BigMAC - Army]

The Army's MBA and MHA include a year of OJT type residency I believe.

[bettermj]

The Army's MBA and MHA include a year of OJT type residency I believe.

Well, that doesn't surprise me. The army programs have everyone beat it seems. :)


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[MmacFN]

One thing important to note.

People with MBAs who plan a career in it goto programs which provide them with a few "internships" at companies. One buddy i have did the online/class MBA which has no internship, it has been 2 years and he has yet to get a job. Other buddy went to a school which is well known and does internships, he started at 110K a year at one of the companies he interned at.

MBA by itself is really pretty useless. You can get all that info online. Its applying the info to a business that matters and anesthesia is so different that from what many have told me it simply does not apply.



Ok..... Working on it.

To add, The MBA I earned was a lot of fun. It was applicable to just about any business. Learning accounting, economics, HR, finances, and marketing is all very applicable to our industry.

Yet still, unless you are actively doing all the stuff in your own business or career, it's all didactic. Very rewarding on a personal level, and potentially for your career. But again, unless you've actually done anesthesia, don't believe in yourself that you can put me to sleep until you've done your clinicals.... No matter how well you do on your tests. (make sense?). Same rules for business.

I would still recommend one If you're interested. Find one that is entrepreneurial based if possible. Those tend to teach you the nuts and bolts, versus all the intricate theories that you won't need. It's like taking the nursing theory out of anesthesia school and putting in Anesthesia Machines 101.

And I DEF would not take out ANY student loans to pay for ANY MBA program, ever.


Eta: the second and remaining paragraphs are meant for the general people reading, not directed just for Esper.






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[RAYMAN]

One thing important to note.

People with MBAs who plan a career in it goto programs which provide them with a few "internships" at companies. One buddy i have did the online/class MBA which has no internship, it has been 2 years and he has yet to get a job. Other buddy went to a school which is well known and does internships, he started at 110K a year at one of the companies he interned at.

MBA by itself is really pretty useless. You can get all that info online. Its applying the info to a business that matters and anesthesia is so different that from what many have told me it simply does not apply.

Or just read "The Prince" and be done with all of it....

[ethernaut]

Or just read "The Prince" and be done with all of it....

-
Therefore, if he who rules a principality cannot recognize evils until they are upon him, he is not truly wise; and this insight is given to few.

[bettermj]

One thing important to note.

People with MBAs who plan a career in it goto programs which provide them with a few "internships" at companies. One buddy i have did the online/class MBA which has no internship, it has been 2 years and he has yet to get a job. Other buddy went to a school which is well known and does internships, he started at 110K a year at one of the companies he interned at.

MBA by itself is really pretty useless. You can get all that info online. Its applying the info to a business that matters and anesthesia is so different that from what many have told me it simply does not apply.


That sounds about right.

If you are doing it for personal growth and satisfaction, it's worth it.

If you're expecting it to land you a great job, you'll be disappointed.

Of course there is a continuum between both ends.

Like I mentioned earlier, it helps land job interviews. It is a great conversation piece when you meet the person interviewing you. It's nice because it shows that you have potential to learn some pretty interesting things outside of one's comfort zone. Also, if I ever decided to do something outside of healthcare, it gives one a little edge.

But if I was expecting to have a great job handed to me or a pay raise after I finished, I'd been disappointed. I did it for personal reasons. So I am pleased.

It doesn't make my patients feel any safer when they learn I have an MBA.










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