Anesthesiologist vs. CRNA

okayestEMT

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For a long time now I've been hoping to complete an Anesthesia residency after medical school (considering everything goes as planned) and I had an interesting run in with a retired nurse anesthetist two nights ago. So I'm splinting her ankle and giving her crutches and out of nowhere she tells me she worked as a CRNA for 23 years. I proceed to tell her I'm hoping to go into Anesthesia as an MD. She blows that idea off and insists that a CRNA is the same as an Anesthesiologist. Now, I recognize the bias in her opinion but what are some of your experiences going through medic school and who did you work with while in the OR?
 

Handsome Robb

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Psh... AAs are better than both! ;)

@jwk


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Akulahawk

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I was hoping nobody had laid the foundation for a full-up flame war but it seems I was wrong. There are big passions (phone wanted to put "pains" instead of "passions" so even my phone knows) around this topic so I'll just say it now: please tread lightly, be professional, and just be nice to each other.
 

Handsome Robb

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Ultimately at the end of the day CRNAs and AAs are mislabel practitioners whereas an Anesthesiologist is a residency trained and in certain specialties fellowship trained in anesthesia...if you look at the amount of education for an AA/CRNA vs an MDA I personally think that speaks volumes.

With that said I think CRNAs and AAs are a valuable and integral part of the anesthesia care team.


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EpiEMS

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She blows that idea off and insists that a CRNA is the same as an Anesthesiologist.

If that were the case, ceteris paribus, then there wouldn't be anesthesiologists*. QED. ;)
*Given that anesthesiologists are pricier to train, etc.

With that said I think CRNAs and AAs are a valuable and integral part of the anesthesia care team.

This is the most important thing for us all to recognize. You've gotta have options - and from a systems perspective, it makes a heck of a lot of sense to have people of varying skill/education levels. Take a rural hospital as an example: In most states, you can have a CRNA there (call it, $150k/year), who has medical direction (I forget the specific term) from a remote anesthesiologist, so that the hospital has anesthesia services, but doesn't have to pay a (full) anesthesiologist's salary. Heck, in 15 states, a CRNA can work without anesthesiologist oversight - and boy, are they cheaper to hire than an anesthesiologist!

We have AAs and CRNAs for very much the same reason that there are PAs and NPs.
 

Carlos Danger

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There certainly is a lot of politics in anesthesia, and it is getting worse as the push for increased utilization of non-physician providers gets stronger. Tensions are much, much worse between CRNA's and anesthesiologists than they are between any other group of physicians and their non-physician counterparts.

The ASA puts out a lot of propaganda that is meant to scare surgeons and the general public into believing that anesthesia is not safe without a physician present; a stance which is categorically and verifiably untrue, and which almost no one in the surgical and anesthesia world actually believes. I am proud that the AANA's official stance and published responses are not nearly as hostile to the MDA's as the ASA is to CRNA's, but it is true that there are many, many individual CRNA's who feel that supervising anesthesiologists as a whole are lying parasites that do nothing but place economic drag on the healthcare system.

I stay out of the politics. I don't even go to state or national meetings because so much of what goes on there is just political, which, while necessary, just isn't my thing. In the interest of full disclosure, I do donate to the AANA-PAC, which I am comfortable doing because I believe that the AANA is very civil and fair towards the MDA lobby and that most of the AANA's political actions are simply defensive. I give respect where it is due and withhold it where it is not - regardless of the individuals post-nominals.

I won't get dragged into a debate here over whether or not CRNA's are "as good" as anesthesiologists. Instead I will post a handful of points that are either verifiable facts or at least statements that I can defend confidently. I'll reply to questions and responses, but I'll simply exit this conversation before I'll argue.
  • Anesthesiologists are generally better trained than CRNA's. I say generally, because I don't think that is always the case, and I think individual factors have a fair amount to do with how strong of a clinician one ends up being. CRNA training is not like NP or even PA training - it is very rigorous and focused.
  • Where anesthesiologists have a big advantage is in the the area of sub-specialization. There are many fellowships available to physicians* that aren't available to CRNA's. Still, a fairly small percentage of anesthesiologists (~20%, I think?) are fellowship trained.
  • Anesthesia was a nursing specialty for decades before it became an organized physician one. That doesn't mean that physicians weren't involved in or practicing anesthesia back then - they were - but it did not become an organized profession for physicians until until long after it was a nursing one. The book that Chase linked to above is an excellent history of anesthesia in the US.
  • CRNA's are trained in all the same anesthetic techniques and trained to manage all the same cases and all the same types of patients that MDA's are. There is literally nothing that an anesthesiologist is trained to do that a CRNA is not trained to do. You can argue that in some specific areas MDA's tend to have better training (as I stated in my first point), but a few years out of school I think that advantage matters little. At that point, for most people their competencies are based more on what they've been doing regularly for the past few years.
  • CRNA's are held to the same legal standard as anesthesiologists. The anesthetic standard of care is the anesthetic standard of care, and the legal responsibilities and obligations are the same, no matter what letters are behind your name.
  • Virtually all of the military anesthetic care provided on the battlefield and other austere places is done by CRNA's. Anesthesiologists simply don't exist - or at least are very uncommon - in the forward surgical units. Same on deployed naval ships. Same in many government hospitals.
  • Only one state (NJ) requires that CRNA's be supervised by an anesthesiologist. 22 or 23 states have no oversight requirements for CRNA's at all; CRNA's are 100% independent practitioners in these states. The others require some sort of (usually very loose) collaboration with a physician, dentist, or podiatrist. In SC, for instance, a CRNA can work 100% independently as long as they have a "practice agreement" which outlines "practice guidelines" with any physician or dentist. These practice "guidelines" can simply be a letter with the statement "Will practice to the currently accepted anesthetic standard of care". It needs to be updated annually. There is zero requirement for medical direction or chart review or oversight of any kind. The doctor does not have to be available by phone. The doctor is not legally liable for the CRNA's actions. NC is similar.
  • Around 70% of all anesthetics delivered in the US are delivered by CRNA's. Many are supervised in some fashion; many are not.
  • About 50% of CRNA's practice autonomously; the other 50% work with some sort of supervision. "Supervision" can be anything from the CMS's "medical direction" which requires close supervision, to a situation where the anesthesiologist is in the building and available but has nothing to do with the cases. Even in the settings where CRNA's are supervised closely during the day, in some of these places the physicians don't do call, or only do call for certain types of cases, and after 3pm or so until 7am the next morning, CRNA's do all the cases independently. So even among CRNA's who are supervised, the ability to practice independently is often expected. The joke among CRNA's in settings like this is that they automatically become much smarter at 3pm.
  • The CMS's requirements to bill for medical direction do NOT require physician oversight for CRNA's. It simply says that if a facility is going to bill for medical supervision of CRNA's, that certain requirements have to be met (the anesthesiologist needs to be present for induction, etc). This arrangement is beneficial to anesthesiologists because they can supervise up to 4 cases at a time being done by CRNA's, and bill for 50% of the allowable payment for each case. So instead of doing their own case where they can only bill 100% of the allowable cost, they an supervise 4 rooms and earn twice as much. The cost effectiveness of this arrangement is obviously questionable, but it is lucrative for anesthesiologists and largely explains why they fight so hard against expanding independent practice by CRNA's.
  • In many rural areas, anesthesiologists do not exist or at least are uncommon. Something like 80% of rural hospitals do not have anesthesiologist coverage at all. Many of those that do have anesthesiologist coverage don't have it full time. If you live in or travel through a rural area - especially in the midwest or western states - and need anesthetic care, chances are much greater that you'll receive it from an unsupervised CRNA than otherwise.
  • Outcomes between CRNA's and anesthesiologists have been studied many times - and no difference has been found. Many of the more respected sources of healthcare policy recommendations (The RAND Corporation, The Institute of Medicine, The National Hospital Association, etc.) have called for loosening restrictions on CRNA's.

* more as a libertarian and taxpayer than as a CRNA, I have a problem with the fact that we spend billions of dollars a year in federal funding to subsidize residencies and fellowships for physicians, but not for non-physician professionals.
 

MonkeyArrow

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All things considered, if you were to go under the knife in another state completely independent of where you work, and thus, don't know any of the practitioners, would you choose a CRNA or MDA? @Remi

Personally, I would feel more than comfortable with a CRNA for the vast majority of procedures, but for things like cardiac surgery with CPB or transplants, I would prefer a MDA.
 

Carlos Danger

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All things considered, if you were to go under the knife in another state completely independent of where you work, and thus, don't know any of the practitioners, would you choose a CRNA or MDA? @Remi

Personally, I would feel more than comfortable with a CRNA for the vast majority of procedures, but for things like cardiac surgery with CPB or transplants, I would prefer a MDA.

Fair question.

But I think a better question is this: If you need a CABG would you rather have your anesthesia provided by a MDA who never does hearts, or a CRNA who does them every day?

If I need a procedure done, all I care about is that the entire team is experienced with and good at whatever type of case I am having done.
 

VentMonkey

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If I need a procedure done, all I care about is that the entire team is experienced with and good at whatever type of case I am having done.
100% concur.
 

TransportJockey

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Dumb question. What is an AA?

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Carlos Danger

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Dumb question. What is an AA?

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Anesthesiologist's Assistant.

Their training programs are similar to CRNA's, but they aren't required to have any healthcare experience to get into school.

Primary functional difference between AA's and CRNA's is that AA's always have to practice under the direct supervision of an anesthesiologist.
 

TransportJockey

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Anesthesiologist's Assistant.

Their training programs are similar to CRNA's, but they aren't required to have any healthcare experience to get into school.

Primary functional difference between AA's and CRNA's is that AA's always have to practice under the direct supervision of an anesthesiologist.
Thabk you. I thought it might be something like that, but I wasn't entirely sure.

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VentMonkey

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Anesthesiologist's Assistant.

Their training programs are similar to CRNA's, but they aren't required to have any healthcare experience to get into school.

Primary functional difference between AA's and CRNA's is that AA's always have to practice under the direct supervision of an anesthesiologist.
Anesthesia Assistant. Pretty much a Physician Assistant who specialized in Anesthesia. Similar to a CRNA
Given a recent turn of events on this forum, this doesn't seem like a half bad option.
 

NysEms2117

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@Remi my question would be, are CRNA's usually limited to "shorter procedures" or surgeries, such as colonoscopies, where if i'm not mistaken(which i probably am) is "less work?" due to the fact it is more then likely just a bolus (Just speaking off of what little experiences I have had/seen)? Or can they do the same heart transplant/*insert big organ transplant here* that an MD can. As well as where are CRNA's often seen? Are they in hospitals as much as anesthesiologists? A quick google search said that there are roughly +- 5,000 the same amount of CRNA's as anesthesiologists.
 

Carlos Danger

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@Remi my question would be, are CRNA's usually limited to "shorter procedures" or surgeries, such as colonoscopies, where if i'm not mistaken(which i probably am) is "less work?" due to the fact it is more then likely just a bolus (Just speaking off of what little experiences I have had/seen)? Or can they do the same heart transplant/*insert big organ transplant here* that an MD can. As well as where are CRNA's often seen? Are they in hospitals as much as anesthesiologists? A quick google search said that there are roughly +- 5,000 the same amount of CRNA's as anesthesiologists.

You will find CRNAs (and AA's) doing every type of case.

Most of the anesthesia in the US is delivered by CRNAs.
 

Handsome Robb

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Given a recent turn of events on this forum, this doesn't seem like a half bad option.

I looked and continue to look relatively seriously at AA/CRNA. due to my early life laziness both will take me about the same length since I need a BS either way, CRNA a touch longer due to having to get ICU experience.

My biggest issue with CRNA is I don't really want to work as an ICU nurse. Biggest issue with AA is they can only practice in 17 states if I remember correctly. May be more since I last looked but if it is it's not many more.


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