Anesthesia Deconstructed: Science. Politics. Realities.

Physician Anesthesiologist Dr Matthew Mazurek On CRNA history, politics, titles and surgeon supervision

November 06, 2019 Season 1 Episode 3
Anesthesia Deconstructed: Science. Politics. Realities.
Physician Anesthesiologist Dr Matthew Mazurek On CRNA history, politics, titles and surgeon supervision
Chapters
00:00:43
Dr Mazurek and his journey to Anesthesia
00:06:02
Dr M's interest in anesthesia history and the article he wrote on CRNA history
00:07:43
Dr M on when the ASA and AANA were born
00:09:15
American Medicine in the 1860's
00:10:26
1910 flexner report standardized medical training
00:11:28
Waters Residency 1927 McGee 1909 CRNA program & McGaw
00:15:00
Dr M's Experience with CRNAs
00:17:50
Dr Miller UCSF Chairman has CRNAs do his cases
00:18:26
Conflict between CRNAs and MDs originated with conflict between women and men as it happened during women's suffrage movement
00:23:26
Dr M supported Arizona CRNAs bill to remove barriers to practice and eliminated liability of physicians for CRNAs
00:24:13
Surgeons "supervising" Just does not make sense and MDs/CRNAs are doing the same job
00:26:41
History of CRNAs being supervised goes back to women's suffrage as well
00:28:06
Dr M's idea of how to bring MDs and CRNAs together and how we can find common ground
00:32:26
Dr M's opinion about CMS letting CRNAs do ASC preoperative anesthesia evals
00:37:04
Dr M on "Nurse Anesthesiologist" titles and the politics of AAs
00:41:08
Dr M's parting advice
Anesthesia Deconstructed: Science. Politics. Realities.
Physician Anesthesiologist Dr Matthew Mazurek On CRNA history, politics, titles and surgeon supervision
Nov 06, 2019 Season 1 Episode 3
Michael MacKinnon DNP FNP-C CRNA / Dr Matthew Mazurek

Dr Matthew Mazurek talks about his article on CRNA history, his views on why friction between the CRNA and MD professions originated, a possible solution, why CRNAs should be working to the top of their license, why surgeon supervision is antiquated and how titles do not matter! An amazing discussion with a true advocate for the best patient care and our shared profession of Anesthesiology! 

Article Found Here: https://www.linkedin.com/pulse/crnas-short-history-nurse-anesthesia-future-care-matthew-mazurek-md/

Show Notes Transcript Chapter Markers

Dr Matthew Mazurek talks about his article on CRNA history, his views on why friction between the CRNA and MD professions originated, a possible solution, why CRNAs should be working to the top of their license, why surgeon supervision is antiquated and how titles do not matter! An amazing discussion with a true advocate for the best patient care and our shared profession of Anesthesiology! 

Article Found Here: https://www.linkedin.com/pulse/crnas-short-history-nurse-anesthesia-future-care-matthew-mazurek-md/

Speaker 1:
0:00
Okay,
Speaker 2:
0:02
welcome to anesthesia deconstructed science politics realities. Listen, ms medical professionals join industry expert and Mike McKinnon to discuss the latest science and medical advancements, the effects of our political climate and the realities of today's changing healthcare environment. Let's get started with your host, Mike McKinnon.
Speaker 3:
0:28
I'm here with dr Missouri physician anesthesiologist to talk about his article that he wrote and published on LinkedIn CRNs a short history of nursing asthenia and the future of anesthesia care. Hello, dr Zurich. Great to talk to you. And uh, just tell us a little bit about yourself.
Speaker 1:
0:44
Yeah, good afternoon. First, before I get started, I just would like to put in a disclaimer that the content and opinions and any of the answers that I reveal in this interview here are solely my own and not related to any organization, my employer or hospital or healthcare network for which I work. Um, well, you know, I kind of wandered into anesthesia. I was born and raised in Fresno, California and my passion growing up was astronomy. And I was set on the track for a career in astrophysics and I went to Fresno state, graduated high school in 1989 there in Fresno. And after about a year and a half of physics study, I wasn't growing bored, but I think what was happening to me was I was trying to understand that some of my colleagues and some of them, some of my classmates in school, we're going to be my professional peers as I've moved forward.
Speaker 1:
1:46
Um, there were, uh, dare I say to many a star Trek nerdy type conversations at 2:00 AM and the, uh, the study hall. And I thought, you know, do I really want to turn something I love, which is a great hobby. I'd built telescopes and one variable stars. Do I want to turn it into a professional career and completely dedicate myself to that type of research. So I had taken a course from Philip Levine and the English department there at Fresno state. And of course he was a part Lori yet. So here's a, here's where I wonder, physics spheres to English literature, creative writing. Towards the end of that I had had a series of personal experiences and that made me decide on a career in medicine. What happened was first I had kidney surgery when I was 21 years old and being in the hospital was uh, you know, an eyeopening experience and I was always fascinated by the human body.
Speaker 1:
2:43
My wife was a secretary in a critical care unit and coincidentally I applied for and accepted a job as a living skills instructor with a severely developmentally disabled adults. So the group home there in Clovis, California, it was that experience three years while I was getting my English degree, that made me decide to become a physician. So I applied to medical school after graduating with my English degree. I had to go back and do two years of, uh, post-baccalaureate pre-medical sciences courses, like we're going at chem and bio, chem and cell biology, et cetera, and apply to med school in 1990s by the 35 schools and got my dream shot. Of course out of those 35 schools, what's interesting, I had 29 rejection letters, so six interviews. I got into the UC Davis Irvine and then UCS late in the summer of 97 and you know, they're kind of a turtles advantage.
Speaker 1:
3:48
Seizure had kind of been sown a little bit in me just based on some of what my wife had told me about critically ill patients. And this kind of seems like an interesting career path. Well not, not one to not take advantage of opportunities. My first year of med school I met one of my most important mentors, dr C Spencer Yost who was at UCL South, I believe he's just one of the vice chairs now. He's a critical care trained physician as well. I worked in his lab on volatile anesthetic mechanisms of action with channel potassium channels after my first year of medical school with the genome tech research fellowship. And I carried on that research for the next three years and we published a couple of really interesting articles. One in anesthesiology, one in the journal of biological. And so, uh, sorry, one in the journal of biological chemistry and then applied to, uh, you know, anesthesia residencies, decided to stay at UCLA. It was a great experience. And, uh, here I am today. Love my job. So
Speaker 3:
5:03
that's awesome. That's quite the roundabout way from astronomy to anesthesia.
Speaker 1:
5:09
Well, yeah, it is. When, you know, when I was interviewing for some of my residency program positions, I vividly recall one of the professors looking up and down my resume. Cause I also did agric chemical research in one of those summers in college were dally Lanco on pesticides and herbicides and this kind of thing. And he says, you know, when I looked at your resume, it doesn't look like you really know what you want to do with your life. I said, well, you can look at it that way or you can look at it as, you know, I'm just a, just a kid who's taken advantage of nearly every opportunity that's been thrown out in the front because I'm super curious and I like to learn and, you know, good answer, I guess.
Speaker 3:
5:48
Yeah, that works. And so what ended up, uh, you know, developing your interest in anesthesia history and based on this article, sure. It's not the first time you've written and read about it. What ended up running you down that road?
Speaker 1:
6:02
Well, you know what's interesting is when, when I was an English major, uh, one of my professors, my Shakespeare professor, um, he was, uh, he had a bachelor of science in geology. He had a Juris doctorate and he was a practicing lawyer in Michigan, hated it, went back and got a PhD in English. So he was a Renaissance man. So when I was taking some of my English courses, it became glaringly apparent to me that in order to understand the context for which a piece was written, you had to understand the political, economic, and social environment of the life and times of that individual living with that time period, writing that particular piece. I mean, it's, uh, so with anesthesia of course there've been, you know, numerous advances throughout the last century and I'm always curious, why are we doing it this way today? And where were we yesterday and where would we like to be tomorrow? So of course just being curious, I start digging around in the dirt and you find out all kinds of interesting things. And uh, you know, this article was, was one of them. I've also done a couple of other, uh, history articles and presentations on Chauncey leek and by vinyl oxide. And I did another one on of course there, William MacEwen in the history of intubation. So there's a lot of really interesting stuff out there.
Speaker 3:
7:28
Anesthesia got a really interesting history, particularly how we got to places like blocks and intubation and all the four bills that happened in the way to them. That's for sure.
Speaker 1:
7:38
Absolutely.
Speaker 3:
7:39
And so in the article there was one particular place where you mentioned, um, talking about when nurses and physicians recognize the need to create formal societies and that they happen within a five year period, which you mentioned was not a coincidence and that that does seem to ring true. And what do you, what were you referring to that was the significance of that quick within the two of creating a formal society?
Speaker 1:
8:02
Well, no, that was of course, in the early thirties. And you know, Ralph Waters said, of course, you know, created the first professional MD, you know, formal residency program there and Madison in 1927 and he was, if I'm not mistaken, I believe he was recruited from Kansas and he was originally trained as an obstetrician generalist physician, but had an intense interest in anesthesia and had done some, some of his own research on it. Yeah, of course. Dovetailing with this whole time period, of course, you know, you had the CRNs forming their own formal training programs and I believe I mentioned in the article, Alison G on the West coast in Portland farming one of the first schools in 1909. Uh, during that time period though from 1910 to 1920, there were numerous lawsuits, um, like the angst, the CRNs having an independent type of practice. In other words, they had to be supervised and that sort of thing where, you know, they were basically told, you're practicing medicine, you can't do it, so you have to stop.
Speaker 1:
9:04
Now, of course, this was also at the same time period that the American medical system was recognizing that during the 19th century, I mean, you know, in the 1860s to become a physician, all you had to do is pay somebody in a private school, throw a certificate on the wall and you know, hand out the mercury so to speak. In other words, it really was more witchcraft than it was medicine towards, towards the late 19th century especially. But getting back to that question on, on the organization, the, the organization and the organization of medicine in general too was taking place. It wasn't just an anesthesia, you had other medical societies also forming professional organizations. Um, you know, the AMA of course was becoming more powerful. I just don't, I don't think it's a coincidence because two in 1927 when you had that formal residency program created by, by Ralph Waters, there was then an urgency for, um, you know, other, other programs to kind of consolidate. In other words, it was just kind of a general movement, so to speak, to create a political organization and an academic, you know, organization and setting for both arms of, you know, anesthetists and anesthesiologists to, uh, to move forward.
Speaker 3:
10:26
Right. It wasn't, it was just a, just before all this that the Flexner report came out and that's what really kind of revolutionize medicine, I think. Right?
Speaker 1:
10:33
Oh yeah. The flow, well, the Flexner report was as a man, it really was. I mean, we, you know, especially in the late 19th century, if you think about it yet, homeopaths, um, you had, uh, you know, allopathic, you know, MDs, uh, practicing medicine and there was a lot going on, but the quality, the quality, I mean, we talked about quality of care, you know, 2019 the quality of care and the late 19th century, of course, first of all, we didn't have that much knowledge, but frankly, you know, it was, some of it was dangerous. You know, the homeopaths, early in the 19th century, even around the turn of the American revolution, physicians were bloodletting leeches, putting mercury and arsenic stabs on like that. So, you know, we've obviously come a long, long way in the last 200 years just in the practice of Madison. So.
Speaker 3:
11:25
Absolutely. And do you think, do you think water's Dr. Waters and McGee were aware of each other during that period of time? Or do you think that was sort of happening in isolation?
Speaker 1:
11:35
Well, Magee's program was the no nine and a water's really developed an interest there in the late teens, early twenties, if I'm not mistaken, one 27 from this program. So he's about two decades after her. And you know, the, I think that point in time, by the time Ralph Waters had decided to focus on creating a formal academic department, um, I think Alice McGee almost would have sort of been lost in the noise. There are a lot of schools, so, uh, unless they had perfect, you know, run into each other, I doubt seriously that they were even aware of each other's existence. Now, I don't think that's the case. Most of solely with [inaudible] who was down here in Rochester and the male with the male brothers. Um, I'm, I'm pretty sure he was aware of, of what she had accomplished. I mean, it's just, it's impossible not to. She had published in the Lancet, um, you know, she was, she was kind of famous within the male system and you can't ignore that kind of a history or, or be, you just can't be ignorant of it.
Speaker 3:
12:45
Yeah. It seems like it'd be hard not to be aware of her in particular based upon, you know, the tens and fat 10,000 plus anesthetics performed without a single death, which seems almost near impossible based upon what they were using. But you know, with that kind of a number of people be aware and she published that.
Speaker 1:
13:00
Well, yeah, well number actually it was 14,000. I mean, but still using that 14,000 anesthetics without a death back then with no monitoring. Uh, you know, I mean, you, you're talking, you're talking about a pretty, a pretty remarkable skillset and, and uh, you know, just logically aware knowing what's going on. I mean, that's an incredible, it's actually an incredible feat if you think about it.
Speaker 3:
13:26
Yeah. Extraordinarily vigilant. Yes, absolutely. For sure. And I have one of the things you mentioned in your articles, you had that super cool 1903 certificate of anesthesia, probably one of the first ones ever given from Scotland to a guy named dr Broughton head. You still have it?
Speaker 1:
13:47
Yeah, no, I still do. I've got it kind of in a cubbyhole or it doesn't get much sunlight, but it's still framed up on, you know, I moved to that in Tucson of course, but I got that certificate. Now there's this little history behind that. I was awarded that by a million Larson who was one of my mentors when I was exploring some of the topics and in anesthesia history. And he presented that to me. Uh, Dolly, I forget when, I don't think it was during residency. It may have been, I know when it was. Yes, it was in 2004 and it was at the anesthesia and American at the anesthesia history association meeting in Las Vegas. He presented it to me. So yeah, it's a, yeah, to his sir William MacEwen. Again, you know, he was, you know, a pioneer in his overcast the shores when he was attempting to intubate patients. And of course there were no ventilators, but you know, he had a couple of very bad outcomes that probably had nothing to do what he was doing and more to do with how sick the patient was that he just stopped, stopped doing it, but he was the first to do it.
Speaker 3:
15:00
And so now in your, in your career and your history, what has been your experience generally with CRNs?
Speaker 1:
15:07
Well, generally, I mean, I've used, I've used the CRNs as my colleagues and my partners in an operating room and, uh, you know, I, I'm not wanting to get hung up on a whole lot of titles. You know, I, I worked with CRL days when I was a resident there at UCS and we had more Sierra Rene's there, San Francisco general. Um, I think we had about six or seven. We had one or two of them, one's Zion and there were only one or two at UCS at the time. Of course, that number's completely off now. I think they're 60 or 70, if not more now in the program there at UCLA. But we are doing level one trauma at San Francisco general. And you know, one of these things, of course when you're sitting there eating lunch and you all have the pagers, it really doesn't matter who's, who's going down as your wing man during some of these trauma activations. And you know, especially as an R one when you don't really know that much when you're a CA ones, pardon me? Uh, you really, you're not very fanatic and you just don't have enough experience. I mean, one of the few of the CRNs I worked with, you know, they'd been doing it for 2025 years.
Speaker 3:
16:17
Yes.
Speaker 1:
16:17
And of course they have, they have tons to teach at first year anesthesia resident, you know, I mean, you're basically fresh and green. And so yeah, I worked alongside, then we broke down. They broke ass and you know, we kind of did a little shift thing there at the County as we love to affectionately call it. You know, we never really, we never really thought of anything political skill set wise or anything else. It's just we're here and we're taking care of patients. We're here to do a good job and, and learn from each other.
Speaker 3:
16:51
Do you think that at that time and more or might be more specifically in those facilities that things were just less politically charged than they are today? Or was that very unique to that place?
Speaker 1:
17:03
No, I, I don't know. Um, uh, and I have to speak from, the only thing I can remember from that time period was just making sure I could get enough sleep and I can eat and rent, you know, that kind of thing and learn. Right. Because you know how it is in medicine, you're training programs, medical school and CRS school was like drinking from a fire hydrant, so to speak. And then when you're in training or clinical training, your work and you know, 70, 80 hours a week and honestly you're just, you're waiting to see your, a senior fellow. So I was really wasn't aware of, you know, I wasn't sensitive to, it wasn't allowed. I never even really gave it much thought to be honest with you at that time period. Well, what was, what was of interesting, you know, Dr. Miller, you know, he was our chairman and of course everyone knows who he is. Um, when he was assigned to the, or he would often have a CR and a cover his room, which, you know, I was like, okay, it's Dr. Miller and you know, cover his room. I mean, you know, actions speak louder than words in my opinion. And he was excellent. You know, where I learned, we learned a plan from him. Um, and uh, you know, it's because hopper Miller was pretty busy. He only was, I think he was assigned to a room once every couple of weeks, you know.
Speaker 3:
18:26
Alright. And you mentioned in your article at one point a, there's always been conflict, basically between us. I think more specifically between our organizations than individuals. And a, the quote was with regard to scope of practice, independence, education and organization. And why, why do you generally think that there's been that kind of conflict or difficulty between organizations or maybe even individual providers through that time period?
Speaker 1:
18:50
Well, you know, in retrospect, and this is something I hadn't really thought of when I wrote the article, but I had one of those aha moments. Um, you know, when, when the geese formed the first school in 1909, this was, you know, right at the height of the women's suffrage movement. And if you think about it, most of the nursing hospitalist at that time period, I mean, there were, I have yet to find one, one male nurse anesthetist from that era. Uh, conversely, how many females were also physicians. So not, I don't want to, you know, the thing is, what was happening to was you've got the nurse anesthetist, women organizing, politically learn, you know, to gain right to vote. And we also now have these nurses organizing politically and academically to, you know, formally train each other on performing anesthesia. So, you know, of course went and suffrage passed in 1920 so this time period and this era there was a lot of conflict, not just between, you know, I'm not going to, you know, anesthesiologist or you know CRNs but there was conflict just in the political arena over over women's rights.
Speaker 1:
20:09
So when Ralph Waters of course formed his first dental Cesar residency program, the water babies were all men. I mean, no one, no one can deny that. It's just a simple fact. So I don't, in the modern era it's very difficult to talk about these sensitive subjects without sounding sexist or you know, that kind of thing, which I certainly don't want to. But again, I think that's why people need to appreciate that where you have, where we were in that era is just the way things were at that time period. Here we are, you know, a hundred years later and things have obviously changed dramatically. But I think that some of the, some of the dynamic was fueled a little bit around that. So when Ross waters from the first program and it was very academically minded, he wanted MDs and he wanted, he wanted to basically, you know, bring back the entire practice of anesthesia and to and into a formal medical practice. And of course up to that time period in before the nursing that statistic medical students were doing anesthesia and you know, the training wasn't really very formal.
Speaker 3:
21:20
That really is an interesting perspective. And I think you're right. I think there's definitely true insight there into what, I mean, you know, colloquial people would return to a term that as a gender Wars at a time when, you know, when women were were trying to reach for equality and men, we're still seeing them as less than equal. If you were doing what would be considered a a man's job, quote unquote, that would be a source of contention, you know, that'd be a reason right there. Yeah, that makes total sense.
Speaker 1:
21:49
No, absolutely. And you know, the thing that you chat, it's absolutely, it's foolishness to try to deny a statement like that too. Because, and that's why I said it's like, Whoa, what was real? And so the, you know, the thing is the political organizations, of course a and a, which wasn't been that, that and the ASA of course formed around that time, just after that time period, it came after the heels. I mean it would, there were farms less than two decades after the suffrage movement. So you've got an organization of predominantly women and an organization of predominantly men
Speaker 3:
22:25
and things are still hot
Speaker 1:
22:26
doing the same thing and things are still hot. So when you have, you know, it's, it's one of the things, you know, I've learned in a lot of management courses in my master's program, you know, culture is an exceptionally difficult thing to change. It really, truly is. And, and, and, and a company culture, for example, when you walk into a hospital, I'm sure you've had this, you walked into a hospital as a certain field, the people in the C suite can change, the guy in the lab can change, but you still walked through there and it has a certain feel that feel is the culture of the place. So I think that, you know, some of the, some of the discontents or some of the, I should say this harmony, if you will kind of was probably laid down under that fabric more than anything else. So I don't, cause it does, it doesn't make any sense to me otherwise.
Speaker 3:
23:21
That really makes total sense. I had never thought of it that way before, but it's totally true. One of the things you mentioned is you had supported our efforts and at that time I was uh, involved in the Arizona association nurse anesthetist to push through a bill, um, in related to removing liability from surgeons. And uh, we had a larger bill at that time that didn't pass and you had supported us. And by on behalf of all the Arizona CRNs, I'd like to say thank you for,
Speaker 1:
23:46
Oh, you're welcome.
Speaker 3:
23:46
We, luckily we passed what we really wanted to the next year, which effectively we put in statute that a surgeon couldn't be liable for the actions of actions, negligence or malpractice of a CRA that they worked with a, actually it says a physician so bit really anybody. And that that was, we wanted to take responsibility for our own actions effectively. You know, if you're doing it, you should take responsibility for it. That's how I was raised. Right. What spurred you to want to support us?
Speaker 1:
24:13
Uh, just my experience working there and I was, uh, you know, to be honest, first of all, there's a critical shortage of anesthesia care in rural areas in the country. Um, you know, you, you'd be hard pressed to find an MD or three or four MDs, you know, while willing to process in some of the smaller communities. The other thing too is, you know, my experience so far working with CRNs, you know, as my professional colleagues has been, um, it's been collaborative. And again, I think I said this at the start of the, uh, you know, at the start of the interview, we're doing the same job. We're doing it for the same reasons. And we're, we're both, both sides of the spectrum, very, very highly trained. And you know, we're, we're given, we're given a lot of credentials and we're given a lot of time to develop our skillset, which is, you know, earned.
Speaker 1:
25:08
And I think that too, if we deny, if we deny someone the privileged to basically practice without that supervision from the surgeon, then you're going to be denying care to patients. Especially if this doesn't make sense. I think I kind of point him to this in the article. I really, I can't think of a surgeon. I've never met a surgeon other than, you know, maybe a cardiothoracic surgeon who would feel comfortable doing it. I just can't, I can't think of a surgeon today with the specialties the way they are who are still comfortable, you know, breaking scrub, running across the drape and looking at what we do because it's incredibly complex. You know, we're not doing open drop either, you know?
Speaker 3:
25:54
Yeah. It's, it's not simple. And you know, surgeons in general and get between two weeks and maybe four weeks of an anesthesia rotation, which may or may not be involved. Them actually doing a lot of anesthesia. And so their perspective is not the same as is ours. We're looking at a bigger picture. They're looking at putting the tube between the cords. Most of the time it's a different focus, you know, that's a skill. Everything else is thinking
Speaker 1:
26:17
there's, you know, let's be clear, there's a big difference between, you know, doing the anesthesia and intubating someone. Right,
Speaker 3:
26:23
exactly.
Speaker 1:
26:24
You know, I mean the pulmonologists do it. The ER docs do it now and they run and they can, they actually, you know, do a Briana set of plan if only anesthetic pack, discharge plan, wake somebody up, know when to give narcs, that kind of thing. I mean that takes years to develop and the, the history of course of nurses being supervised again goes back to the early 20th century and the late 19th century where the surgeon of course is considered more or less the captain of the ship so to speak. And of course if you have nurses in there, it's very easy to give them orders on what to do. And my thought then dropped ether. I mean, we're not talking about, you know, we're not even starting IVs on these patients. I mean it's a whole, if we were to go back in time 120 years and see how anesthesia was administered, I think all of us would, would, you know, be kind of an interesting thing to see.
Speaker 1:
27:18
Almost scary if you asked me. But today with the complex ventilators, all the bells and whistles, the variety of drugs, I mean, it's just an hour doing opioid free anesthesia. Uh, and you know, we're running multiple drips for some of these cases. When you walk across and you find the blue drape that what we're doing, there's a lot going on. And I just don't think, I just don't think it's fair to a surgeon to expect them to understand what we do. And that's another reason why I was like, wait a second here. You can't say that the surgeon knows as much as the CRNI they don't, it just doesn't make sense.
Speaker 3:
27:58
Yeah. As a couple of my friends from Alabama would say that dog don't hunt.
Speaker 1:
28:03
Yeah. Right.
Speaker 3:
28:04
And one of the things you mentioned in the article that I thought was really a great idea was the idea of having a joint sort of conference or, or ASA and a meeting to actually sit down and have an honest discussion about the future of anesthesia concerns, getting them together. And I know in the past the, the leadership of the ASA and the Ana have sat together and I know they do currently, uh, have meetings, but as far as a real meeting with members to get together and sit and talk and mix because, you know, I think, I think that things get much easier when you sit in front of someone and have a conversation, you know, you, you've personalized them then, right?
Speaker 1:
28:39
Oh, absolutely. Uh, you know, last fall I attended the Minnesota Minnesota association of nurse anesthetist conference there in the cities. And you know, I was one of what, I may have only actually been one of the only MD anesthesiologists there, but there was a wonderful conference in event I sat in on some of the lectures, you know, the topics are the same. I mean we're talking about people and physiology here that is common between us. I mean, and there really is common ground. I mean we're issues, concerns on topics that are very relevant to both organizations and both types of practitioners. And I think if we were to strike, you know, some ground on common ground so to speak and kind of meet halfway on some of these topics, the shortage of anesthesiologists and CRM, AEs is one of them. What's the long term solution for that?
Speaker 3:
29:36
Or the low, the low pay, the low reimbursement by um, you know, Medicare anesthesiology.
Speaker 1:
29:43
Well, and that's that that affects both organizations as well. Uh, and uh, the recertification thing is affecting the practitioners in both specialties as well with the ABA. And I believe now the nurses are also having to recertify as well as that. Is that correct?
Speaker 3:
30:00
Yeah. With an exam, the whole thing. Yeah. Yeah.
Speaker 1:
30:04
We have a milk and mental thing now for the ABA, which is different than this old 10 year exam. But you know, the principles of it are the same. So we're both, you know, both organizations and not saying they're reinventing the wheel, but we have some common ground to come together on. And I think that would be kind of a bridge for us to forge better partnerships in some settings. I mean, our practice setting is very, very unique up here in Northern Minnesota. I still do my own cases. I don't supervise, like in medically direct, I do the free ops I can do, we do the blocks, we prepare them, the CRNs can do pre-ops and then do their own cases. And you know, we all help each other out. And uh, you know, it's, uh, it's a great environment and I have the students from two of the nurse anesthesia programs here in the upper Midwest who come in and we teach a lot of regional anesthesia. So, you know, that's a technical skill. And you know, in the words of Mark Rosen, who was our residency program director, he said, do you want to teach everyone around you as much as you can? It doesn't matter what their title is. If it's a technical skill, they can learn it. You don't need an MD, you don't need an RN like masking, you know, a patient for instance. You don't need an MD. You need the practice, you know, doing the, doing the bag and the mask so to speak.
Speaker 3:
31:26
Absolutely. Raise all the people up around you too high as possible. And that's all better for patients at the end of the day. Yes.
Speaker 1:
31:32
The end of the day. And that's what Mark Rosen would even say. If you're going to teach somebody how to save someone's life and you've done your job, it's a good philosophy to have.
Speaker 3:
31:41
And I think you're right. I think we have much more in common in our, so even our association level then we, then we don't, it's a, it's unfortunate that there's so much political anx because I think that could be resolved with exactly the kind of idea that you have of have a meeting where people all come together that are open, you know, open, have a discussion about it. Right.
Speaker 1:
32:04
No, no, I was just thinking, I mean, some, you know, what may eventually happen too is, I mean rather than have a formal conference from the societies, I mean CRNs from state groups might just band together with some other varieties from other States and have smaller conferences as kind of an organic start to the whole process.
Speaker 3:
32:25
And one of the things I, uh, that's going on recently you probably know about is, um, CMS has proposed that CRNs should be able to do the pre anesthetic evaluation at ambulatory surgery centers, which effectively is what happens anyway. Right. Um, but, and that, that would be a change from currently, you know, uh, a surgeon if it's just CRNs with surgeons would have to at least sign off in their surgeons record that they, that they agree with the anesthesia evaluation and the plan and you know, organizations are, are against that in general. And the organizations, of course, you know, the ASA as well as the American college of surgeons even came out against that, which is interesting. What is your idea? What do you think about that? I mean you, you're a pretty a political individual. And so when I, when I look at this, I, what I see is, you know, there isn't a surgeon or a podiatrist or a dentist who knows as much about the anesthetic assessment as I do. That's my perspective and I don't know any that I work with of the 20 or so, you know, providers that would ever suggest that they did. You know, they don't question us when we decided to cancel a case cause it's unsafe. So why would that be? Why would they want to be against that?
Speaker 1:
33:32
Yeah. You know, I, I mean I'm familiar with it, but I'm not familiar with, with the resistance. You know, why there would be some resistance. I'll be blunt though. I mean having a podiatrist or a dentist, if you want to say that they're more capable than a CRM a of, of making an anesthetic evaluation, I'm kind of baffled honestly at doesn't even make any sense at all. To me it just doesn't, not even any in any way, shape or form. That's not really a political statement. So much as your train absolutely doesn't give you the experience or the knowledge to make that assessment. You know, for example, let's just say you were going to do a mini of those final on someone with a critical eye and a surgery center. Of course, you know you wouldn't do it, but you know these, these are the kinds of questions on all boards that we get asked.
Speaker 1:
34:29
You get asked as a, as an answer, you know, as a CRN and I get asked on boards, you're going to do a spinal for a hip on someone with critical AIS. No, I'm not going to do a spinal and I can guarantee you a dentist and podiatrists would look at me and say, why not when they would that. Why? Well there's a massive sympathectomy there. Do you know how afterload preload? I mean, do you know there, do you know the real physiological impacts of, of what we're doing and you know, unless you're actually doing that day in and day out the way we do it, because we're not really anesthesiologists, we're not nester fists. We're physiologists is what we are. We are, we are applied or applied physiologist. That's what we do. We altered physiology during the drugs we administer. And unless you're doing that on a day in, day out basis and we're familiar with all the effects, you just can't say that you're going to know what's going to happen, you know?
Speaker 3:
35:22
Exactly. You know, I think, uh, things like pulmonary hypertension and AIS, those are prime examples. You know, I understand what an RVSP is. I understand how to calculate the RSP. I know what PA pressures are. I know when it's going to be too dangerous to do in a particular place. And where I live at 6,200 feet above sea level, part of the anesthetic assessment may be to transfer this case to a lower sea level just to be safe because they'll do better. Right. But even some of our surgeons would look at that and go, well, I don't get it. Why? Because the last time they looked at pulmonary hypertension was probably medical school. You know, that's not their focus unless there may be a cardiothoracic surgeon or you know, a cardiovascular surgeon, one of those two.
Speaker 1:
36:03
No, but I mean, I, you know, I don't want to pick on specialties, but you know, some of our surgical subspecialists, our EMPS urologists are orthopedic surgeons, plastic surgeons, that kind of thing. I mean, they're not, they're not nearly as in tune with that kind of thing as we are. And, uh, and, and I completely agree, which is why I'm saying a dentist. I mean really, I just kinda lost. I'm lost. I'm not saying that, you know, they're, they're good at doing, you know, at dental history and physical.
Speaker 3:
36:35
So, yeah, I agree that it's an odd thing. I mean, I think, you know, I think when you, when you sum it up, ultimately the answer is money. What was the question? And that's kind of what it comes down to. And so you get into these kind of battles for silly, silly reasons when, when ultimately the goal is to take care of patients and you should have the person who is most trained at the job in the, in the position they're in, take care of that PR portion that they're most educated in. Really. I mean, I think that's a no brainer for just about anyone looking at that from the outside. The other thing I wanted to ask you about is there's a, there's a movement in the CRM, a community and the Ana is, um, recognize this as a descriptor, uh, utilizing the term nurse anesthesiologist.
Speaker 3:
37:15
And I think the reason that that's been pushed has been related to sort of anesthesiologist assistants utilizing the term anesthetists. So, you know, in, in the U S anesthetist has always been CRDA anesthesiologists was developed and created to be a physician anesthesiologist. Whereas of course in, in the UK and Australia, this is exactly the opposite, all physician and all anesthetists. But this has been sort of a movement to separate CRNs as sort of an independent provider from an AA as a dependent provider because there's been a movement to lump them all in together. Basically. What, what is your take on that kind of thing?
Speaker 1:
37:52
Well, you know, I mean that's, that's part of it. But you know, now that most of the CRA programs, they're going to a doctoral program. Now we're going to have DMPs. You know, in fact, I actually have, you know, one of my colleagues here, um, you know, she has her doctorate in nursing practice and for all intents and purposes, there's no rhyme or reason why she can't, you know, introduce herself as dr XYZ right now. She doesn't do that because in her world, she doesn't want to misrepresent herself as an allopathic physician because I think that's what, you know, patients expect. If you walk up and you say your doctor X, they're assuming you've gone to medical school, you know, as far as far as I'm concerned. And I did the whole title thing. It just, I, I don't get it. And I get it in some levels. I mean, it's just one of these ways where we have to kind of distinguish ourselves on one front to differentiate our training. Um, but, uh, you know, the, the, the whole AA thing, that's another political, that's another political arena right now. I mean, if you think, if you think about it, it's another layer of complexity. You know, that's kinda been introduced. And, uh, right now it remains to be seen where, how all of this is going to unfold.
Speaker 3:
39:09
Yeah, that's for sure. It's complicated. And you know, we're in a time when there's economic pressure on healthcare so there's going to be more and more. I'm looking for more and more alternative models in order to meet these needs effectively.
Speaker 1:
39:23
Well it's similar to what's happening in a lot of primary care practices and even hospitalist practices. They have NPS and they have PA's, you know, they basically have the three layers system and the same, same. I mean in my opinion it's the same kind of thing happening now with anesthesia, AACR, nays and DS. You know, the thing is though, what's going to happen, and I've, I've written this on some other articles on LinkedIn, I think that, you know, the role, the role of the anesthesiologist and, and, and anesthesia care, it's extending way beyond the operating them anymore. You know, their Loma Linda, I believe now has a nurse anesthesiology hospitalist program where the anesthesiologists basically are responsible for the entire perioperative care period. And the surgeon has been, you know, I'm not going to say relegated into a technology, you know, a technician, but the anesthesiologist's managers, their pain, et cetera, and the surgeon nouns as a consultant, not as the primary caregiver and their length of stay decrease.
Speaker 1:
40:25
You know, so that's a, you know, it's kind of, we're seeing a lot of different, remarkable things happen in medicine right now. I think that the most important thing is for us not to get hung up on, on who's got what title on and that kind of thing and more realize that we're all bringing different perspectives to the table, a different training experience that table, but all for one common goal, which is to really, you know, take great care of people and do it in a lot, you know, do it with less money. Uh, we have to be focused on that as well. You know, we have to be more economically minded.
Speaker 3:
41:00
Yup. I agree. Totally. So this has been a great interview. You've been great. And, uh, what is the last thing I'd like to say is, uh, what would you like to say to CRNs physician, anesthesiologist who may be listening to the podcast? What message would you like to leave with them?
Speaker 1:
41:16
Well, you know what, it sounds really cliche, but you know, we're kind of all on the, we're all in this together and we're all on the same team at the end of the day. Uh, you know, we've worked alongside each other for, for decades, taking care of patients and saving lives and that's what we're going to continue to do. And I'm passionate about my job. I absolutely love anesthesia. I love my practice and I love working with my MD colleagues, tRNA, colleagues, my surgical colleagues, the nurses on the floor, anyone who's in that, in that common goal. And I think, I think that the number one thing is, you know, and I, I say this especially at this time in medicine, don't forget why we're doing what we're doing. It's a calling, you know, it's a professional calling to do what we do. It's also a privilege to be able to do what we do. And not everyone has the, has the capability to take care of people the way we do.
Speaker 3:
42:09
Absolutely. Matt, you have been a total breath of fresh air. I intentionally, and when I set up this podcast, I want to talk to not just the RNA physicians and get perspectives that were, that were, you know, kind of apolitical and just interested in exactly what you just said. We're all in it together. We're all trying to do our best for patients. You know, you got into it because you wanted to take care of patients ultimately. And so that's the goal. Right. Thank you so much for agreeing to come on. Amazing article that you wrote. Uh, I think everyone in the anesthesia, no matter what their title, appreciates, people like you.
Speaker 1:
42:44
Alright, well thank you very much for your time.
Speaker 2:
42:47
That's all for this episode of anesthesia deconstructed. For more information based on today's discussion, be sure to visit us@anesthesia-deconstructed.com you'll also gain access to our blogs, editorials, and more resources to keep you updated on the science politics and reality's come today's medical industry. That's anesthesia-deconstructed.com.
Dr Mazurek and his journey to Anesthesia
Dr M on when the ASA and AANA were born
American Medicine in the 1860's
Waters Residency 1927 McGee 1909 CRNA program & McGaw
Dr M's Experience with CRNAs
Dr Miller UCSF Chairman has CRNAs do his cases
Surgeons "supervising" Just does not make sense and MDs/CRNAs are doing the same job
History of CRNAs being supervised goes back to women's suffrage as well
Dr M's idea of how to bring MDs and CRNAs together and how we can find common ground
Dr M's opinion about CMS letting CRNAs do ASC preoperative anesthesia evals
Dr M on "Nurse Anesthesiologist" titles and the politics of AAs
Dr M's parting advice
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