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Saturday, April 12, 2008


I've been trying to be a good student today, working on my pharm exam which is on Monday. At some point I was looking up student nurse anesthetist blogs (perhaps wondering why I was doing this on such a beautiful day?) and found some interesting complaining going on from MDs. Nurses and MDs are always going to be at odds for something, if not at an individual level than certainly at the group professional level. MDs as a group seem to be constantly amazed that a "mere RN" can do as much as we can with "almost no college education." They talk a lot about how we only need 2 years of college to be a nurse--which of course isn't true even if one does get an associate degree instead of a BSN, because of the prerequisites required to get into the 2 year program. But about half of us have bachelor's degrees. Anyway. For the physicians, everything begins and ends at how much college education one has. Without as many years of college education as a physician has (which can be argued, is only about 50% useful to them--their bachelor's degree was probably in a science and geared towards med school acceptance, but it is not medical education) one obviously can't be allowed to do work that is "important" or be compensated anywhere near what an MD is compensated.

So this blog discusses the "problem" of CRNAs being paid more than family practice physicians are paid. Its author, California Medicine Man, points to another blog by a guy called KevinMD that outlines the outrageousness of this problem:

CRNAs (Certified Registered Nurse Anesthetists) make almost as much, if not more, than primary care physicians - with 2 years of college education. This post from a forum wonders how:
  • CRNAs make 224% as much as RNs and 156% as much as advance practice nurses (NP). According to the allnurses.com website, 58% of nurses are certificate nurses only, ie. have no advanced degree beyond a RN. It is not clear whether all these nurses were trained in 2 year certificate programs or whether some may have been trained in 18 month programs . . . Most of these CRNAs with a diploma RN and a certificate CRNA are still in practice and therefore have only 2 years of college education, period.

Some are even wondering if FPs can go back a re-train as CRNAs:

  • I wonder what would happen if a FP tried to apply to CRNA school. Certainly the degree they have qualifies them over a mere RN degree. Then they would go to work as a CRNA. From there it's hard not to see them lobbying to have full anesthesiologist status.

CMM points out that in fact, CRNAs don't have just 2 years of college education. CRNA certification requires education for 2-3 years at a masters level, which requires a bachelor's degree (which, by the way, is actually a health care science degree, not a general science degree like MDs). But the point of practicing as an Advanced Practice Nurse is that our experience in nursing is valued in lieu of additional college training. And, since when is the amount of time put in a university a direct correlate to amount of compensation that can be expected? In a lot of MD's minds, years of college=dollars earned. CMM goes on to explain that this isn't about education but the law of supply and demand. Isn't that terrible, that family practice doctors aren't as valued as CRNAs, so they get paid less, when they are educated for 4 years longer than a CRNA? (This is playing a bit fast and loose with the numbers. He quotes 7 years of college education for the CRNA vs. 11 years for the FP doc. The last 3 years are residency for family practice medicine. They are paid while completing this residency. And we already discussed the first 4 years.)

That last bit by KevinMD (actually just quoted by him, I think it's actually from a student physician message board) is why CRNAs and MDs will never truly get along. How simple, a FP doc just bypasses anesthesiology residency by applying to CRNA school, because "Certainly the degree they have qualifies them over a mere RN degree." And then "it's not hard to see them lobbying to have full anesthesiologist status." First, no CRNA program (except maybe the ones owned and run by MDAs, but I doubt even them) would accept a family practice doctor into their program. The programs require being an RN, having a BSN or its equivalent, and having nursing experience, almost always at least 2 years in critical care. Being a FP doc doesn't meet any of those requirements, much less exceed them. CRNAs have a strong lobby and professional consciousness, and they would never allow an MD into their program so he (not she) could leapfrog into practice as a MDA. A FP doc does not have the bedside critical care experience necessary to start as a student nurse anesthetist, and would be behind the 8 ball from the beginning. He might have the intellectual knowledge, but not the experience. How many PA catheters does a FP doc place, and interpret? How many times has he managed a septic patient? Oh yeah, none. And then there is the issue of the ASA (the American Society of Anesthesiologists). They would NEVER allow anyone, not any kind of MD, to become a board certified anesthesiologist without completing a 4 year anesthesiology residency. Period. The ASA argues that CRNA education is inferior to anesthesiology residency, anyway, so no grandfathering would ever occur with their blessing, because that would be admitting that CRNAs and MDAs are essentially interchangable. The ASA vigorously opposes that position.

I don't mention all of this because I think it's a reasonable possibility that it could happen (although I'll bet someone has tried). I just use it to illustrate the amount of hubris that many in the medical community have with regards to nursing. Physicians are highly educated, and many of them are extremely knowledgable and outstanding clinicians. Not all are; they have a spectrum of ability and intelligence just like any other profession, and it's not as oriented towards the top 5% as most people think. But they make the mistake of valuing formal education, its amount and where it came from, over actual knowledge, intelligence and expertise. This dismissive attitude towards nursing specialties, and nursing in general, is evident nearly everywhere. This kind of thing gives nurses a big chip on their shoulder. Would you like working with this sort of thing hanging over you all the time? It's a wonder that nurses play as nicely as they do. The professional CRNAs that I have seen navigate this minefield with a remarkable amount of grace.

And, for the record, CRNAs are paid more than FP doctors because they are more in demand and they are sued way more often than FP doctors. They carry much higher malpractice insurance. And the burden of responsibility is higher. FP docs do have a lot of responsibility, and I don't diminish their expertise or importance one bit. But they would not trade the level of responsibility or the insurance premiums if offered.

Thus endeth the sermon.

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