Nurse Anesthetists working without physician oversight

[Chrisada]

I'm glad someone brought up the PA issue. I was upset a few weeks ago when I made an appointment with a dermatologist, and was instead seen by his PA. The issue for me was that it was not disclosed. The PA came in with a long coat and a nurse, and I thought he was the Dr. until I was checking out and saw two names on the business card. I then asked who saw me, and was told it was a PA. I just looked up PAs and read that for their three years of training towards a Master's degree, they can make up to $200,000. Holy crap. DH went the wrong route!

[PrincessFiona]

This is a self made problem. Physicians have hired out for the less demanding issues, are backing out of hospital call and are making themselves less necessary. Our internists here no longer round on hospital patients. They are less productive than the mid-levels, who with experience are seeing more difficult cases. Now that some make more money they are upset.

[Chrisada]

I also just remembered that the group I saw when I was pregnant with DS1 had me see only a NP until I got to a certain number of weeks. Then I would have began seeing the Dr. I moved so I never actually got to see the Dr. except for my very first visit for a pregnancy test.

[Thirteen]

I had a situation back when I had the ankle surgery in March that is along this thread: post-surgery (I think it was 8 weeks out), I had made an appt in advance, w/ the Dr., to be evaluated. The morning of the appt., I receive a phone call 25 minutes before my scheduled appt., telling me that the PA is going to see me instead (which I was fine with). I arrive, wait 2 hours, and then am called to the front desk because apparently the PA is "not qualified" to see me for this particular visit, and would I mind coming back another time or rescheduling?

This is longwinded, but what I'm trying to say is why would you assign someone to do something who is not qualified to actually do it, if that's the case? I understand this is an intensive specialty and is not FM (as was suggested earlier), but are there similar stories for people in FM? Can you say that a PA is not qualified in one area, but is qualified to do my DH's job? Is that true?
(FYI: This is something that really grinds him; I'm honestly just curious as to what you all think).

See, the "protect the medical degree" argument is my least favorite. If there's no need for anesthesiologists, keeping spots for them for the sake of keeping spots for them is just dumb. Now, I don't think that's true in this case. According to DH, when things go wrong with anesthesia, they go wrong really quickly, and CNAs aren't trained as well for the true crises. So to me, that's the value of having an MD available.

If medical training is valuable (and I think it is), its value should be apparent. If it isn't, maybe that's something we need to take a closer look at.

My thoughts exactly. It's not about protecting DH's job - and we probably shouldn't even get started with this issue in Ob/Gyn. But it's a matter of training, and what you do when things start going really wrong really fast.

The thing is, this was reviewed by a panel of physicians, and they got input from additional physicians. I have to think they hashed through all of this, maybe even looked at statistics re: errors by certified nurse anesthetists. I guess their "risk/benefit analysis" was that the lack of coverage is a more immediate and damaging problem than lack of MD oversight. What I wonder is whether they're doing anything to recruit more rural MDs, or if they're giving up on that.

[scrub-jay]

My thoughts exactly. It's not about protecting DH's job - and we probably shouldn't even get started with this issue in Ob/Gyn. But it's a matter of training, and what you do when things start going really wrong really fast.

The thing is, this was reviewed by a panel of physicians, and they got input from additional physicians. I have to think they hashed through all of this, maybe even looked at statistics re: errors by certified nurse anesthetists. I guess their "risk/benefit analysis" was that the lack of coverage is a more immediate and damaging problem than lack of MD oversight. What I wonder is whether they're doing anything to recruit more rural MDs, or if they're giving up on that.

CO is HUGE on recruiting/training rural docs. But as for doing an appropriate risk/benefit analysis here is a letter from CO Medical Society (as well as the organized group of CO surgeons and anesthesiologists) asking the Governor to NOT make this decision and to meet with physicians to discuss other possible solutions. The Governor ignored the request and made his decision without physician organization input. http://cms.org/ASAP/ASAP.html

[alison]

According to dh, you can teach a monkey how to do anesthesia.

But when the shit really hits the fan -- well, you don't want your anesthesiologist to be a monkey nor a CRNA, imo.

[Vishenka69]

My DH pretty much agrees with Alison's. He actually prefers supervising to doing his own cases. That way he's only involved in the interesting part and is there when his skills are truly needed.

In regard to CO, I wonder what would happen if surgeons refused to operate without an anesthesiologist present. It seems that pretty soon there will only be a handful of states that are friendly toward physicians. But hey at least we'll all live close to each other.

[Amiens]

As another anesthesia spouse, I just want to chime in.... that my dh says the same thing that Alison's dh did. He says it ok for CRNAs to do their job, they have a purpose, but are not trained to the extent to handle the major crises. He has had to save a CRNA's hide more than once, and he says that it the benefit of having an MD supervise.

[ladymoreta]

DH also agrees - CRNAs are a huge help, and I think they get along great. (I kind of expected they wouldn't since this is a fairly common anesthesiology debate.) The ones he works with seem happy with MD oversight and that they can do their shift and go home.

DH also agrees - CRNAs are a huge help, and I think they get along great. (I kind of expected they wouldn't since this is a fairly common anesthesiology debate.) The ones he works with seem happy with MD oversight and that they can do their shift and go home.

It's seriously *the* perk of doing the CRNA route. Great money, hands-on, "interesting" stuff (as opposed to a lot of scut work) w/o the malpractice liability. If I had any, ANY interest in science and/or aptitude for gross stuff, I'd totally go that route.

[Chrisada]

It's seriously *the* perk of doing the CRNA route. Great money, hands-on, "interesting" stuff (as opposed to a lot of scut work) w/o the malpractice liability. If I had any, ANY interest in science and/or aptitude for gross stuff, I'd totally go that route.

Yes, I've been trying to get my brother to go into this. But sigh, he really really wants to be an MD instead. Just took his MCAT.

DH was driving sleep-deprived this afternoon, so I had to think of something that might get him riled up enough to stay awake. This topic worked. He does locum tenens in rural areas quite a bit, so he operates with a nurse anesthetist every time he does a c-section in these towns (I assume some would be with epidurals, others with general anesthesia). Basically he said that yes, ideally, you would have an anesthesiologist, but it's just a fact of life that you aren't going to get the same quality of care in these areas. It's either providing care in suboptimal settings or transporting several hours. Part of the solution, in his opinion, might be establishing better guidelines for when to transport. One of the towns, for example, is considering transporting anyone over a certain BMI because of the difficulty of protecting the airway.

We met a locum tenens surgeon at the hotel on one of our stays. I don't know whether he might have a different opinion, considering the different kinds of procedures he would do. DH's perspective is that you have to count on your crash team, ER doctor, and the nurse anesthetist for emergencies, and you have to know which patients to transport for surgery in a place with better resources.

[scrub-jay]

Deb - (or anyone)

What does your DH think about telemedicine as a possible solution? As in: having an anesthesiologist on a screen (or able to hop on a screen) if trouble arose? UC Davis in CA does this with many of the small rural hospitals to bring specialist expertise when transport is 4-5 hours away.

[alison]

I don't know... When dh is called in to place an iv that a nurse or crna can't get, I don't know how helpful it is to have him try to do this from our couch.

I know I'm sounding super blasé about this, but I just don't see how crnas can work entirely independently.