Medical Idiocracy

Medical Idiocracy*

 

The following was inspired by the presentation of the ASA president and the SAB plenary session at this year’s AUA meeting. It is reprinted  from the  Summer 2008  AUA newsletter.  http://www.auahq.org/Summer2008.pdf

  

 

What a trip! An hour ago I entered the UPenn hyperbaric chamber but there was a power surge and poof! The lights went out, the barometric pressure undulated up down and all over and I found myself in the chamber after the lights came on but different folks were running the unit. I looked at the clock and it was the year 2050! I stepped out to find the tech frantically turning knobs and spinning wheels and trying to figure out what was going on. He did not seem very able as a problem solver.

(The hyperbaric technical society, founded in 2010 and following the lead of the nurses, successfully lobbied and got a law passed in 2020, giving the techs full autonomy to run hyperbaric chambers. The PhD’s all were released. In a repeat of the scenario that occurred with the 20^th century steelworkers, most enrolled in nursing school as a pathway to a remunerative, satisfying, autonomous career.  Notably, the Journal of Hyperbaric Medicine, receiving an insufficient number of submissions, stopped publishing in 2031.)

Wow! I thought. Its 2050! I couldn’t wait to find out how Anesthesiology had progressed and was eager to check this out. So I ran over to the hospital, now called UPMC-HUP (yes…..UPMC bought the UPenn Health system in 2025) to check things out. I really wanted to observe things in my old neuro rooms.

The neurosurgery advances were just magnificent. The robot worked wonders and all the guess work was gone. The UNIX-versant neurosurgeon put the patient in pins, programmed the computer, and was able to oversee six craniotomies at once.  Very cool. But the anesthesia…..the anesthesia was a different matter.

(The many patient safety efforts of visionary MDA’s that started in the mid 20^th century progressed through the first two decades of the 21^st century. The APSF’s work continued with 50 research grants annually, over 60 patient safety standards in effect, and over 100 instructional patient safety oriented videos in use by 2020. Anesthetic death and morbidity was approaching zero. However, The AANA, after a persistent and brilliant lobbying campaign,  got a law passed in 2015 which allowed them to practice independently while concomitantly increasing the number of CRNA and PhD-level CRNA graduates…all according to their secret strategic plan laid out in 2001 and implemented with little resistance from the highly paid, overworked,  and otherwise complacent MDA’s of the early 21^st century. The law specifically allowed PhD level CRNAs to present to patients as their anesthesiologist and their anesthesia doctor. In addition, over the next five years,  in the context of a catastrophic health care funding crisis with rampant systemic rationing of resources,   the AANA brilliantly and  effectively argued that each SRNA was self-funded and MDA’s were overpaid with no added value, given the spectacular safety record of anesthesia. Moreover, they convinced the legislators that it would be in society’s interest to stop funding all MDA anesthesiology residencies.  The federal health care act of 2020 provided for no funding for MDA training while abolishing anesthesia-related lawsuits.  This contributed to the spectacular growth of SRNA residencies over 2020-30. Third world health care, already dreadful, became a calamity as nurses from those countries flocked to the USA to take the newly vacated, well compensated bedside nursing jobs.)

So, my old anesthesia department, august tradition of Dripps, Eckenhoff, and VanDam notwithstanding, was phased out of the medical school in 2030 and now the CRNA PhD’s were running the anesthesia service line.  I must admit they ran an efficient operation. Everyone got propofol, vec, and desflurane. All got the same airway management and most of the patients that I saw woke up just fine.  I was told there was the occasional stroke and the occasional cardiac arrest and post op MI, and sometimes there was an difficult airway related death. In fact the anesthesia death rate had risen since 2008 and those who did not do well in surgery had a financially mandated withdrawal of support. Things like this were necessary in a world with more beneficiaries than workers; it seemed like these negatives were acceptable cost benefit trade offs in order to keep the federal health service running. Other than that it was just like 2008, but with shorter turnover times.

I found one of these latter day anesthesia doctors so I could have a discussion about what was going on. I was eager to hear about how the nascent issues of 2008 neuroanesthesia had grown. So I asked, what had happened to developments in genomics to tailor anesthesia? What about the new brain protection strategies? Had the new laser IR to support brain ATP been translated? Surely that was in use by neuroanesthesiologists of 2050. What new drugs had been developed? How about blood substitutes? Any new monitors? Any continuous CBF and CMRO2 monitors that were being discussed in 2008?  New simulation technology?  Had anything changed since 2008?

The anesthesia doctor I spoke with looked askance at me and suggested that there were no significant problems, the surgeons had solved all the important problems and all the stuff I was asking about, after review by the Best Practices Board of the AANA, had been dropped as just expensive  fluff stuff. They were doing just fine without it.

So after a week or so in 2050, I headed back to the chamber and hoped the “hey dude” gang could get me back to 2008. 

 

 

Story line adapted from the new cult movie, “Idiocracy” If you’ve never heard of it learn more from http://www.imdb.com/title/tt0387808/ or http://en.wikipedia.org/wiki/Idiocracy or just google it.

 

Comments

[Nursing Jobs in USA]

Interesting site about the Medical Idiocracy.....

[Disgusted by your statements]

Honestly, you should be ashamed of yourself for spewing such absolute propaganda, fear mongering and lies.

Show me the evidence where CRNAs have caused all these things in practices? They dont exist and all the studies that do suggest otherwise.

I have no respect for anyone who makes up stories with which to scare the public and harden physicians against nurses without any basis in reality. If you want to know why CRNAs often have disdain for MDAs all you have to do is look in the mirror.

[Haha]

Earth to bow-tie anesthesiologist.....that was a ridiculously lame story - as high quality as any Bush/homeland security "it could happen" fear mongering.

[kofke]

this is an admittedly hyperbolic piece of fiction. however there have been events that very well could make much of what i predict a possibility:

AANA for years has been preaching that anesthesia is the practice of nursing not medicine and thus MDs are not needed

AANA has frontally assaulted the medical practice of anesthesia by actively working to decrease funding for anesthesia training programs. this has nothing to do with crna practice and everything to do with a tactical move to diminish or eliminate a political opponent

AANA actively opposes efforts to expand AA practice. AA's work under licences of supervising MD's unlike nurses

SRNAs in many programs are calling themselves residents....why would that be?

PHD CRNA's are increasing presenting themselves as dr so and so without clarifying their lack of medical training.

all of the major advances in anesthesia that have made it so safe have resulted from research performed in academic medical centers under the auspices of physicians.

I dont know why we cant just keep working together well like we have in past years. the AANA's work to expand scope of practice seemed a fair argument. However, I personally have become radicalized in my views when the AANA started activities that attacked the medical specialty of anesthesiology by so vigorously working against the teaching rule, something that really has nothing to do with CRNA practice and indicates other motives.

ak

[Disgusted by your statements]

Kofke

I appreciate you actually wanting to discuss the issue so I thought I would take the time to reply. Dont take offense to the "MDA" term, it isnt meant that way just shorter to type for me :)

You said:
"AANA for years has been preaching that anesthesia is the practice of nursing not medicine and thus MDs are not needed"

Well, it has been established in law that the practice of anesthesia is both medicine and nursing. This isnt an opinion, its the reality. I have never once seen anything put out by the AANA which has said that anesthesia isnt also the practice of medicine. I have also never seen anything put out which suggests that MDAs are not needed.

In fact, I would say MDAs are the ROOT of the science of anesthesia. Without physician scientists where would we be? I dont, however, agree that a physician is needed to provide safe and effective anesthesia.

You said:
"AANA has frontally assaulted the medical practice of anesthesia by actively working to decrease funding for anesthesia training programs. this has nothing to do with crna practice and everything to do with a tactical move to diminish or eliminate a political opponent"

The bill the AANA supports (6331) gives back money to BOTH SRNA and MDA programs. The teaching bill, if passed as the ASA wanted, would provide an economic incentive NOT to train SRNAs over MDAs. The bill as the ASA wanted it would change the pay scale for 2 MDA residents to 100% of the billing structure from medicare TO and MDA who is supervising the 2 rooms. However, if they were supervising 2 SRNAs they would ONLY be able to collect 50% of each case or a total of 100% as opposed to 200%. Clearly this is a financial disincentive to private anesthesia grps or hospitals if they collect all the billing. There is simply no other way to interpret it. 6331 will keep the playing field even where a supervising MDA OR CRNA for 2 SRNAs will also get 100% of the billing for each case up to 2 SRNAs.

Obviously this in NO WAY harms anesthesiology teaching programs but the ASA bill certainly would.

You said:
"AANA actively opposes efforts to expand AA practice. AA's work under licences of supervising MD's unlike nurses"

Of course we do. The ASA created AAs for no other reason than to oppose CRNAs with their own dependent provider by design. We see AAs as the ASAs attempt to replace us in the market. A perfect example is texas. There are literally THOUSANDS of MDAs waiting to be licensed in texas yet the ASA was pushing for AA schools to be open. Clearly this makes no sense.

AAs represent a group of people who cannot compete with MDAs for contracts and that is the goal of the ASA.

You said:
"SRNAs in many programs are calling themselves residents....why would that be?"

Where people get the idea that 'resident' means only doctor i dont know. However, the fact is its semantics. If i said resident nurse anesthetist what would it matter? For the record, personally, i dont see any reason to call SRNAs residents nor would i support it. I simply think it muddies the waters. However, i would never 'legislate' words which are general in nature as proprietary of physicians.

The same is true of the title Doctor. While i would never introduce myself as doctor in a clinical setting to avoid having to explain it, the title is not unique to one practice. In fact the title that is unique to you is 'physician'.

You said:
"PHD CRNA's are increasing presenting themselves as dr so and so without clarifying their lack of medical training."

Really? Please cite when you have personally seen this happen. I know MANY PHD CRNAs who have never used the title doctor in front of patients.

You said:
"all of the major advances in anesthesia that have made it so safe have resulted from research performed in academic medical centers under the auspices of physicians."

I agree.

You said:

"I dont know why we cant just keep working together well like we have in past years. the AANA's work to expand scope of practice seemed a fair argument. However, I personally have become radicalized in my views when the AANA started activities that attacked the medical specialty of anesthesiology by so vigorously working against the teaching rule, something that really has nothing to do with CRNA practice and indicates other motives."

I agree. I work great with my MDA colleagues. I also have no problem with indy CRNA practice. However, I do believe you may have it wrong when you suggest the AANA is trying to stop physician anesthesia programs or create a fiscal issue within them with 6331. It was the ASA that created a unilateral bill which would be anti-competitive via medicare reimbursement. The AANAs original bill included BOTH MDs and SRNAs. How is that trying to attack you?

Thank you for actually responding and explaining. I appreciate the discourse and look forward to your reply. If you can see my email id like to talk further, feel free to email me.

Mike

[Mitch Keamy]

Well, this is the "bow-tie anesthesiologist" chiming in, as distinct from Dr Kofke, my friend and blog co-author, who posted here. My feelings regarding nurse anesthesia were clearly articulated in a prior post "We have met the enemy and he is us..." You can find it here:
http://mkeamy.typepad.com/anesthesiacaucus/2008/02/we-have-met-the.html

I find this whole line of AANA/ASA discourse to be a little over-wrought, to be honest. But let me re-iterate what I have said before; without academic MDA's like Kofke and O'Conner, CRNA's can eventually expect to be paid a two dollar an hour differential from ICU nurse pay; after all, as the administrators will reason "they are only nurses..." CRNA's OWE THEIR PRINCELY (AND PRINCESSLY) INCOMES TO THE TIRELESS WORK OF ACADEMIC MD ANESTHESIA DEPARTMENTS (and so do I). So, pound away at MDA's all you want, BUT SUPPORT ACADEMIC ANESTHESIA.

Read my prior post if you don't get this...

[gas man]

Hi all,

congrats on a wonderful blog.

I am a trainee anaesthetist from the UK. The physician kinds (there is no other kind here)

was looking for a fellowship programme in the states a few months ago and was introduced to the CRNA vs MDA debate raging in the US these days. And oh my god!!! Do you guys fight or what...

this discussion to be sure is much more civilised than a few others that I have chanced across.

How did this come about, I mean, nurse incursion into a hardcore medical field...

Just curious

[Gas man]

http://content.healthaffairs.org/cgi/reprint/7/4/26.pdf

scary stuff this.

[andrew kofke]

thanks for the article reference.
Indeed, some anesthesiologists use their CRNA team as their ATM with little actual medical input. I should write a caustic article about that practice which I think fuels the whole controversy

ak

[Mitch Keamy]

Dear gasman:

there is a great story surrounding the rise of nurse anesthesia in the US. Whereas chloroform was initially the preferred agent in the UK and Europe, In the US it was ether.

Chloroform is an unforgiving anesthetic, in that it sensitizes the myocardium to the dsrhythmogenic tendencies of catecholamines. The initial tendency was to lighten the anesthetic depth in response to the deaths, assuming some direct chloroform toxicity, which only increased endogenous catecholamines.
Ether is very forgiving; since it is a respiratory depressant with rapid lipid uptake, patients who become too deep hypoventilate, lighten up as the ether redistributes to the lipid rich/well perfused muscle compartment, and self correct. Therefore it was reasonable to have the janitor or Sister (nun) slap a sponge on the patient's face and pour on a little ether. As a consequence, anesthesia seemed complicated to the Europeans, and simple to Americans. The rest, as they say, is history!

[Shaking my head]

"Therefore it was reasonable to have the janitor or Sister (nun) slap a sponge on the patient's face and pour on a little ether. As a consequence, anesthesia seemed complicated to the Europeans, and simple to Americans. "

Your Hubris and ignorance is infinite.

[Shaking my head]

oops correction...

Your hubris and ignorance ARE infinite.

[Jo]

Thank you Mike for writing such an objective and researched response to this fictional blog. As a nurse anesthesia student, my classmates and I wrote letters to our legislators regarding Bill 6331 and how it would negatively impact OUR education not MDA residents.

I am proud to be a nurse anesthesia student and when I do get my PhD I will NOT use the title doctor in the clinical arena because I want my patients to know who I am and the outstanding record of safe care my nursing profession has delivered since the 19th century. All the doctoral CRNAs I know feel the same way.

I appreciate BOTH the nurse anesthetists and anesthesiologists who work hard to educate me during the clinical day. Jo

[Agreat CRNA]

He probably wrote this while a CRNA was busy doing his case!

[Jo]

Dear Shaking my Head,
I think we all can agree that anesthesia in the United States and across the pond was rudimentary in the 19th century compared to today. I was wondering if you had ever heard of Alice McGaw termed the "Mother of Anesthesia" by Dr. Charles Mayo for her work as one of the first anesthesia providers in the United States. She worked at St. Mary's Hospital in Roch, Minn. She is credited with advancing safety in the operating room and the open drop inhalation anesthetic using ether and chloroform. Hundreds of physicians and nurses from across the world came to Minnesota to observe her technique in the 1890s.

Over the course of her career she wrote 5 noteworthy papers. One published in 1906 in Surgery, Gynecology and Obstetrics was entitled "A Review of 14,000 Surgical Anesthetics" (3:795). It reviewed 14,000 surgical procedures with nurse anesthetists that showed no complications or death attributed to problems with anesthesia or its application. I would not call this slapping a sponge on a patient's face.

I just wanted make you better informed of the early history of nurse anesthesia practice.

A recent review of over a 1,000,000 obstetrical anesthetics performed independently by the Health Research and Education Trust entitled "Anesthesia Provider Model, Hospital Resources and Maternal Outcomes" showed no difference in the safety record of anesthesiologists and nurse anesthetists. Glad we are all keeping up the good work and I hope we can constructively work together in the future to better patient safety.
Thank you, Jo

[Jared]

Hmmm.... interesting hypothetical points however; as well educated and trained individuals we must defer to the research of CRNA and MDA models of anesthesia. I am unaware of any valid research which would support your claims. We can and do work together in many environments where MDAs do not attempt to thwart or otherwise hinder a CRNAs practice and continued growth opportunities.

[Shaking my head]

Jo,

I was speaking to the "bow tie" MD. His hubris and ingorance is infinite as marked by his comment.

[Jo]

my apologies Shaking my head, my eye for sarcasm must be poor after night call :-).Jo

[G. Peterson]

What a bunch of bullshit Andy!! You really shouldn't be writing about CRNA's when you don't have the facts correct. I would think that someone as bright as you would be able to check out the truth before you post wrong information!!!!!!

[G. Peterson]

Would all of you please get your facts correct. It is a Doctor of Nursing Practice DNP......not a PhD that is the future of the Nurse Anesthesia Profession. With that, I can introduce myself to my patients as Doctor so and so, and I will be your nurse anesthetist....

The word Doctor does not originate from Medicine...A doctorate is an academic degree that in most countries represents the highest level of formal study or research in a given field.

MDA's are physicians but nurses, pharmacists, physicians, physical therapists, audiologists etc etc etc earn the title of Doctor!!!! It is so sad that I have to explain this to someone who has a doctorate as well. Apparently they didn't teach you very well in med school.

All you MD's on this kick to bash CRNA's are threatened for your jobs. You have to prove why you need to be involved. Well truth be told.....the majority of you are not needed. Just wait until HMO's and Health Care Facilities start saying enough is enough and begin weeding out MDA's, and therby reducing the cost of anesthesia health care!!!

[Andy Kofke]

Before I wrote this I pretty much thought the machinations of the AANA to expand CRNA scope of practice was a reasonable activity even if it did not agree with it. I was fairly apathetic about the whole issue. But when the AANA went after the foundation of academic anesthesology, the residency programs, I became really quite radicalized in my views about what has been going on and I came to believe the motives of the AANA were not limited to expanding scope of practice but rather to eliminating or seriously limiting MD anesthesia practice. Thus I concocted the fictional story of one possible outcome of their being successful.

By and large the CRNA's I have worked with over the past 30 yrs have been competent and collegial. I just urge everyone to think about the impact of limiting the growth of academic anesthesiology and the negative impact on everyone that could arise therefrom.