Peter Schorsch
First things first. Kudos to Sen. Anitere Flores for wanting to make cosmetic surgery safer (SB 732).
Cosmetic surgery sounds safe enough to anyone who hasn’t blown an evening watching “Botched,” but several clinics in South Florida have recorded deaths following elective procedures.
The impression of safety is no accident, it’s effective marketing. Plastic surgeons ply their trade as a quick and easy fix for irksome imperfections, but often fail to inform their patients exactly what they’re signing up for: surgery.
And surgery is never easy.
But that’s not what this blog post is about. Nor is it about the never-ending scope of practice wars, although that is somewhat of a factor.
This post is about the vexing testimony of a plastic surgeon who went before the Senate Health Policy Committee Monday. Instead of calling him out by name, lets refer to him as “Dr. Butt Lift” because, well, that’s what he does.
By way of background, one of the scope-of-practice battles that has taken place is between physician anesthesiologists and certified registered nurse anesthetists (CRNAs). The focal point of this food fight is whether or not CRNAs can or should be able practice without the supervision of a medical doctor.
Until Monday, nobody had claimed that CRNAs are more qualified than physician anesthesiologists.
In fact, that claim would be an absurd one, even to the CRNA lobby. Rather, they claim that they’re not ersatz replacements for anesthesiologists, but adequate ones who know their craft well enough to handle most procedures without physicians looking over their shoulders.
(It’s kind of hard to get behind that argument, however, when their own reports show that narrative has some significant plot holes.
Regardless, that’s the point they’ve been pushing for years, and more power to them even though I wholeheartedly disagree.
Not to the testimony of “Dr. Butt-Lift.”
He’s a South Florida (see a pattern here?) physician who specializes in buttocks enhancement surgery and who made the ridiculous and completely unsupported — and unsupportable — claim that nurses are actually better trained than physician anesthesiologists.
Yes, he actually said that.
It should go without saying, but physician anesthesiologists are better trained — by an almost exponential factor. They have to ace undergrad, attend four years of medical school and then complete a four-year residency, including a year of hands-on education in surgery.
CRNAs get specialized training too, but they’re in and out of a typical post-grad program in 28 months.
So, eight years of postgraduate education and training for the physician compared to two years and change for CRNAs.
Stacking those credentials against each other makes it clear that physician anesthesiologists have more extensive training and a better grasp on all phases of surgery than their CRNA counterparts.
Now, there may be reasons for someone to have concerns with Flores’ bill — and there is room for that conversation. But the opponents of her bill lose any shred of credibility when they make the kind of outlandish comments that “Dr. Better Butt” did.
25 comments
Nurse Anesthesiologist
March 12, 2019 at 5:01 pm
Besides that what you post is totally unsubstantiated opinion, the fact is Nurse Anesthesiologists (CRNAs) are JUST AS SAFE as Physician Anesthesiologists (MDAs). it is not a debate.
I love that you used botched as an example. They use independent CRNAs in many of their operations as well. I know because multiple friends have worked for them and even made it to TV.
Anesthesia
March 12, 2019 at 5:36 pm
No such thing as a nurse anesthesiologist
AnusTeaseEeeHollaGist
March 12, 2019 at 10:14 pm
Eff U!
Anesthesia
March 13, 2019 at 8:25 pm
“Observe which side resorts to the most vociferous name-calling and you are likely to have identified the side with the weaker argument and they know it.”
– Charles R. Anderson
Urnurseanesthesiologist
March 18, 2019 at 8:43 am
Of course nurse anesthesiologists are more proficient they perform the actual job on a daily basis It’s only natural that the “supervising” physician anesthesiologist lose their craft over a short period of time. They spend this time pumping themselves up though verbally and mentally
Israel
March 18, 2019 at 10:13 am
This can be measured. It would be a great idea to measure the proficiency of supervising physicians and their skills and compare them to independent CRNA… some MDA shy away from OB anesthesia as some CRNAs shy away from cases involving lines and difficult techniques. It would be interesting to have an MDA vs CRNA showdown
Anaesthesia
March 19, 2019 at 5:02 pm
No MDA degree out there. There are MDs and DOs. MDA is some nurse construct.
Agatha Hodgkins
March 19, 2019 at 8:18 pm
No such thing as a physician anesthesiologist until long after CRNAs had been running the field. Anesthesia is a nursing practice, it fits in the care model. Anesthesia renders a patient without pain and therefore the ability to care for themselves, so therefore a nurse does it. Anesthesia does not fit with the cure model of medicine. Anesthesia allows for the diagnosis or treatment by the procedurals. A diagnosis is rarely made when anesthesia is being given. Probably why other physicians think of it as an ancillary subspecialty… that can be carried out by nurses…
Janitor Anesthesiologist
March 12, 2019 at 7:32 pm
Hi BoltCRNA!!! You are not even a ‘Nurse Anesthesiologist’ yet go back to studying please
Truth, nothing more...nothing less.
March 12, 2019 at 7:01 pm
Dr. Nurse Anesthesiologist! DNP, APRN, RN, MSN, BSN, ADN, CRNP, CCRN, MEHJIEKSNDUKEOEOALZKZNMAJJA!! How many more titles do you all need? Still doesnt make you better than a physician trained in his/her speciality. Never ever will! Let that sink in.
Steve Tucker
March 15, 2019 at 5:44 pm
The facts are simple, these “nurses” could never compete with the intellect and abilities of the physicians. If they could, the nurses would have had the credentials and ability to matriculate into medical school. Not to change the narrative, but Dr. Butt-lift is a total Butt-head. I could train a surgical tech to do a better job than he (in fact many surgeons have techs close their wounds and the techs do a superior job than the surgeon) but would never suggest that a technician is “better” than a surgeon. Butt-lift’s comments demonstrate typical surgeon hubris, arrogance, and mis-informed myopia.
JR
March 12, 2019 at 7:18 pm
Laughable. “It’s not a debate”.
If it wasn’t a debate, nurses would be providing anesthesia independently in every hospital in America….which they’re NOT. The fact is the vast majority of cases are done by either anesthesiologists alone or anesthesiologists supervising nurses.
The data is out there on that, so that is not a debate.
The fact is, the overwhelming majority of hospitals in this country require anesthesiologists on staff supervising nurses (if they even have nurses) because they know better.
When patients are polled in all these states they overwhelmingly want a doctor in charge of their anesthesia, not a nurse.
A nurse doing some butt lifts on healthy patients is a far cry from the surgical needs of most patients in this country.
bpcmd
March 15, 2019 at 12:42 pm
Why not name the identity of Dr. Butt?? If he testified in a public hearing, there is no reason to cloak his identity.
I’m sure his opinion is skewed toward whatever can potentially make him the most money as to who can provide “better” anesthesia care.
Nurse Anesthesiologist
March 18, 2019 at 12:59 am
I practice independently in Seattle, WA hand by hand with an amazing group of Nurse Anesthesiologist and Physician Anesthesiologists. We work together and collaborate. We replace in cases, give lunches to each other and there is not fighting because EVERYONE WORKS.
Unlike my experience in Florida where my “attendings” spend 5 minutes in a 5 hour case and they called ”supervisión”.
You can call it whatever you want. We know it is money.
Gas-man
March 18, 2019 at 9:00 am
1) Every INDEPENDENT study shows that anesthesia care provided by independent CRNAs is just as safe as anesthesia care provided by physician anesthesiologists or ACT models, including studies by the federal government: this is FACT.
2) CRNAs already practice independently in most states and the US military with exceptional safety records… including in war zones to service members who have received horrific injuries unimaginable to civilians, and they do so with over a 90% survival rate: this is also FACT.
3) The ASA completely misleads the public on the training of physician anesthesiologists vs CRNAs, to the point of outright deception. Medical students receive ZERO training in anesthesia during medical school, and ZERO during their internship. The only anesthesia training they receive is during a 36 month residency (which also includes external rotations to places like the ICU… so not a full 36 months). CRNAs receive their Bachelors in Nursing, and then work in critical care settings for an average of 4-5 years prior to beginning an average of 30 months of graduate training for anesthesia, during which time they receive the IDENTICAL training on physiology, pathophysiology, pharmacology, and anesthesia that MDs learned during medical school (because only a complete narcissist would be so blind as to believe that it is impossible to learn medicine from anywhere other than a medical school… anesthesiologists learn stock trading without going to business schools: SRNAs can learn medical sciences from other sources as well). In fact, most CRNAs train along side anesthesia residents, and do identical cases, get the exact same pimping, and are expected to perform to the exact same standards as the anesthesia residents they’re training alongside. Finally, the board exams that MD anesthesiologists and CRNAs take are identical. All of this is FACT.
4) The last factor is cost: care provided by CRNAs is less expensive that care provided by anesthesiologists. The Anesthesia Care Team model that the ASA falsely promotes as being safest does nothing more than allow physician anesthesiologists to bill more and therefore receive more money than if they actually did cases themselves. This is FACT, and every anesthesiologist knows this.
The fact is that the ASA and all the state anesthesiologist associations are only interested in their bottom line, but they hide this fact behind a false and disingenuous claim of concern for public safety, when all the research clearly shows that they’re wrong.
Ptsbeforeprofits
March 18, 2019 at 11:27 am
So, so we’ll said! Indisputable!
Dan Giraffe
March 20, 2019 at 12:53 pm
The author of the column has it 100% correct. Anesthesiologists are better educate and trained and the superior anesthesia provider.
Gas-man, please post the citations to the “INDEPENDENT” studies you are referencing. These studies previously released by the nursing community all include the tiny print at the end that says “Paid for by the American Association of Nurse Anesthetists.” Funding source = high risk of bias.
An actual independent study by the U.S. Department of Veterans Affairs is worth reviewing: “In general, patients managed by solo CRNAs were less complex than those managed by solo MDs. Despite adjustment for patient characteristics (age, sex, and race), procedure complexity (captured with procedure base units), and year, the methods used in the study to capture the complexity of surgery and relevant comorbidity were not adequate to exclude selection bias as an explanation for the results. That is, the lack of differences in patient outcomes might be due to triage of less complex cases to CRNAs. The results of these studies do not provide any guidance on how to assign patients for management by a solo CRNA, or whether more complex surgeries can be safely managed by CRNAs, particularly in small or isolated VA hospitals where preoperative and postoperative health system factors may be less than optimal.”
Gas-Man
March 22, 2019 at 7:10 pm
Here are 4 independent sources, including a very one showing a 0.27% complication rate for MD only anesthesia practices, and a 0.23% complication rate for CRNA only anesthesia practices (patient acuity was statistically the same for both groups). Sorry it took a few days, but I was on vacation and had more important things to worry about.
https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2008.0966
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2677049/?report=reader
https://www.medpagetoday.com/meetingcoverage/acg/42402
http://wana-crna.org/files/1314/1339/6545/CochraneReview.pdf
Meeturnewanesthesiologist
March 18, 2019 at 10:00 am
I have to ask what a political writer actually knows about medicine? Nothing. The universal language they do speak is MONEY and that is what this argument is truly about. Don’t be distracted by all the chest pounding. Nurses have been administering safe anesthesia for over 100 years without supervision all across the country and still do.
Israel
March 18, 2019 at 10:10 am
Who is better is an opinion based on individual preference. Here is an article with some facts… not opinion
https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2008.0966
Dan Giraffe
March 22, 2019 at 10:19 am
Israel’s “facts” from the Health Affairs article? Not credible.
Make sure you read the entire document including the end where the reader finds the disclosure:
“This research was funded by the American Association of Nurse Anesthetists.”
Just the facts
March 19, 2019 at 9:29 am
The public should be asking how much the Florida Society of Anesthesiologists paid this publisher to LIE to their faces. The physicians all seem to practice based on actual evidence, until the research doesn’t say what they want it to say. Florida legislators will find out quickly that every single study supports independent CRNA care, and the physicians will once again be revealed as putting their own interests ahead of the interests of Florida patients.
Gas-Man
March 22, 2019 at 7:54 pm
Here you are, Mr. Giraffe: several independent studies regarding anesthesia outcomes, including one that shows a 0.27% complication rate for MD only anesthesia practice and a 0.23% complication rate for CRNA only anesthesia practice, with patient acuity rates being spastically identical between both groups. I know the rates for both groups are statistically insignificant, but you do notice who’s rates are lower, don’t you? Sorry to let facts poop in your Corn Flakes, but the fact is that CRNA only anesthesia care is equally as safe and costs far less.
https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2008.0966
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2677049/?report=reader
https://www.medpagetoday.com/meetingcoverage/acg/42402
http://wana-crna.org/files/1314/1339/6545/CochraneReview.pdf
Dan Giraffe
March 24, 2019 at 7:46 pm
Here you are, Gas Man:
1 & 2) Studies were funded by the American Association of Nurse Anesthetists. Not independent by any measure. Of course a study paid for by the AANA is going to suggest nurses provide the same level of care as physicians. Funding source=high risk of bias (Cochrane).
3) You want to take credit for safer colonoscopies? Uh, ok. The study was self-reported (people are only going to report when everything is OK), retrospective and a single-center. Weak.
4) The Cochrane paper said they could not tell if nurse anesthetists provided the same level of care for any number of reasons including they couldn’t tell whether a physician was actually providing clinical oversight of the nurse or whether the nurse was alone.
More to the point, if Cochrane actually suggested that nurses provide the same level of care I don’t think pages 15 – 16 would be required:
The Cochrane paper says that a randomized clinical trial (RCT) in which an anesthesia provider is randomly assigned to a patients without regard to the patients condition (sick or health, young or old) or the type of procedure (complicated or easy) being performed – could answer the question. However, the paper states such a trial would pose “logistic difficulties in terms of allocation concealment and blinding of participants and personnel. Further, randomization may be unacceptable to health service providers, research ethics committees and patients, particularly for high-risk patients and procedures.” (p.15-16).
“MAY BE UNACCEPTABLE TO…PATIENTS” Why would be unacceptable? Because no hospital, university, patient would risk such a crazy study. Independent nurse practice is too risky to even test for high-risk patients and procedures.
With regard to the question of nurse anesthetist costing less. If you are talking about cost of education? Yep. Your 24 months of nurse anesthesia school and your 100% on-line DNP vs. medical school, residency and fellowship (no on-line stuff) – you win. If you are talking about cost of care, if you are a nurse anesthetist, you know that Medicare and virtually all commercial payers pay the same for an anesthetic procedure regardless of whether it is an anesthesiologist, nurse anesthetist or the team. Right? Now if you really are willing (gas) man-up, send a letter to CMS with a cc to ASA and tell them you want to be paid less than an anesthesiologist per procedure. Go ahead and make my day…
Gas-Man
March 26, 2019 at 6:10 pm
Way to stick your neck out there and only focus on one article, while ignoring the others, Mr. Giraffe… I guess they don’t fit your bias. Too bad you lack the intellectual honesty to admit that the only “research” that has shown that there is any benefit to MD supervised anesthesia care are funded and sponsored by the ASA… though I’m not surprised. You also lack the intellectual honesty to openly admit how much MD anesthesiologists get to bill above and beyond the actual cost of anesthesia delivery by “supervising,” which usually means sitting on your ass checking stocks, and being in the way when you actually do venture into an OR. Are you willing to man up and tell CMS that you don’t need to be paid extra to sit on a chair “supervising?” I didn’t think so either… and yes, I’m more than happy to tell CMS they can reimburse me less for doing the actual work.
Comments are closed.