If you’re wondering what a CRNA (Certified Registered Nurse Anesthetist) does compared to an AA (Anesthesiologist Assistant) or a physician, this episode will enlighten you! Tune in as your host, Jenny Finnell, dives into the things that a CRNA actually does. She also touches on opt-out states and what that means as far as the CRNA practice. Whether you’re just starting to explore this career path or getting ready to start your program, this information is a powerful tool in your arsenal to help you understand what being a CRNA is all about.
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What Does A CRNA Do? What Does It Mean To Be An Opt-Out State? What Is The Difference Between AA, CRNA & MD?
We are going to cover what a CRNA does as far as what their practice is like and what it means to be a CRNA opt-out state. I’m also going to compare and contrast the role of a CRNA and an AA, which is an Anesthesiologist Assistant, as well as an MD anesthesiologist. That way, if you’re wondering what the heck is the difference or what a CRNA does compare to being an AA or a physician, I’m going to enlighten you in this episode. We’re also going to touch on being an opt-out state briefly and what that means as far as the CRNA practice.
I’m excited to share this with you because speaking from being a CRNA for over six years, it took me that long in my career because it wasn’t something that I paid attention to and even honestly figured out, which is sad, but I’m being truthful. I’m happy that I get to enlighten you and also be upfront and honest with you. A lot of CRNA programs are expecting their candidates to understand these differences prior to even coming in for their interview.
Sometimes they may ask what’s the difference between an AA and a CRNA. You would have to enlighten them on what you know about that or what it means to be an opt-out state. A lot of these programs want you to understand this concept even prior to going into CRNA school. Even if you’re starting to explore this career path or whether you’re getting ready to start your program, this is a topic that you should be well aware of and understand.
This is a great tool for you to put in your arsenal to empower you and understand what being a CRNA is all about. First and foremost, I want to start this episode off with this. As a CRNA, you work collectively as a team and always act out of respect. A big part of being a professional in a career path, especially like a CRNA, is being respectful as a team. Whether you’re working with and tending to the anesthesiologist, an AA, or another CRNA, it’s always about respect at the end of the day and working collaboratively as a team.
That’s the key component that I want to start this whole episode off with. Back to understanding, tell me the difference between a CRNA, AA, and MD because some of these schools may ask this question in your interview to gauge your understanding. What they’re also looking for you is to see if you’re willing and able to understand the responsibility that you’re getting ready to accept. You are accepting a very large responsibility as a CRNA because we are independent practitioners.
They want to make sure that you understand that while your scope of practice can vary from facility to facility and also your personal choosing, for the most part, they want to understand that you understand that you are taking on an independent practice role as an advanced practice nurse. In this episode, I’m going to uncover what it means to be in an opt-out state and the various types of practices that CRNAs work in. First and foremost, what types of settings do CRNAs practice? What kind of surgeries do they do? Is there anything that they can’t do under their current scope of practice?
The easiest and shortest answer for that is there’s nothing that we can’t do under our scope of practice. We can provide surgeries for all types of surgery, whether open-heart, pediatrics, obstetrics, regional, pain management, dental clinics, ophthalmology clinics, fertility clinics, and ketamine clinics. Many CRNAs I know start their pain clinics and run their ketamine clinics. We even can do med spas where we do a lot of different types of injections along that line of work.
There’s a lot of variation and practice, not just hospital work. There are a lot of things that you can do on the side- colonoscopy clinics, endoscopy clinics, and those types of things. The vast majority of us probably all start in some type of hospital setting. I wouldn’t advise you to go straight into working at a dental clinic or an ophthalmology clinic right out of school because you could be limiting your experience and your skill set by doing that. It doesn’t mean that if you choose to do that, it’s impossible for you to ever go out and get other experience.
The longer you only do that one experience, the harder it’s going to be to branch out. The mindset I took on when I was a new grad was, “Give it all. I want it all.” Still to this day, I try to seek out experiences in my career path that will challenge me and my knowledge, education, and skillset because, for me, not only is that fun…I mean, yes it’s uncomfortable. Don’t get me wrong. It is completely uncomfortable to force yourself to step out of your comfort zone, but that truly is where the gold is. That is where you grow.
You know this because you’re embracing being a part of this show, going into CRNA school, and doing all the things to get there. It doesn’t stop once you become a CRNA. If you keep that mindset that you had prior to even pursuing this career path, you’re going to have such a rewarding and fulfilling career. In my humble opinion, you should always seek out new opportunities because that brings a lot of fulfillment and satisfaction to your career path.
I wanted to do open-heart. That was what my calling was. I was in school, I didn’t have an open-heart background; I was a NICU nurse. Early on in my nursing career, I was a nurse’s aide. They would float me to the open-heart unit. I had a couple of traumatizing experiences as a nurse’s aide. In one of them, I was trying to get the patient out of the chair. He was young, in his 30s. He had an open-heart; I was getting him out of the chair so early! He had this giant chest wound.Is there anything that CRNAs can't do under their current scope of practice? The easiest and shortest answer for that is no. Click To Tweet
I was helping him out of his chair. He coded and fell on top of me. I remember screaming for help and trying to push him off of me. He was heavy. It was terrifying. It left an impression where I was like, “I never want to do this as a nurse. This is terrible that this happened.” I watched this young man code after all that. Another time I went there, there was this young girl my age. She’s a twenty-something-year-old girl who had post-pregnancy cardiomyopathy.
They cracked her chest and did a sternal massage on her heart right in front of me. I was like, “They do that. You have to be kidding me.” I was a nurse’s aide. I was very young. Pretty young Jenny was like, “No, thank you. I want to stay far away from that.” I worked in the MICU as a nurse’s aide. I worked there as a nurse even though it was challenging. There were a lot of comorbidity patients. For some odd reason, when I got to my cardiac training in school, I loved pathophysiology. I thought it was the coolest. It made sense to me.
It was one of those concepts and areas I enjoyed learning about and watching the surgery. The surgery is the coolest thing…to see a beating heart stop and start back up again. It’s seeing the cardiopulmonary bypass machine. Everything about it fascinated me and lit me up. Even though I didn’t have the best experience in school as far as getting a lot of open-heart numbers, I made it my mission to pursue cardiac as an anesthesia provider when I was done with school. I did that for about four and a half years before we relocated to be closer to family.
That being said, I’ve also challenged myself to go back to doing Peds. I’ve challenged myself to go to a place where I would get heavy regional experience. It’s something that I had not had since school. I had on-the-job training doing popliteal, interscalene, superclavs, saphenous, and adductor canals. Those are the primary blocks we did, but I did a lot of them. In one week, I would do 30-some blocks. I got proficient quickly. I always challenge you, no matter what you do, to seek out different opportunities as a CRNA. It affords you more opportunities down the road when other positions pop up.
There are specialties like peds you can work in. There are adults, hearts, kids, or either one. EP lab was in the realm of hearts where you’re doing electrophysiology, AFib ablations, cardioversions, obstetrics, labor and delivery, putting in epidurals, things like that, and doing spinal for C-sections. I did do that. I joined a call team when I joined the heart team. I did 24-hour shifts. I did a lot of OB on those 24-hour shifts, mostly at night.
The way we did it is we did have an attending in-house, but we had two 24-hour CRNAs for the most part unless we needed an MD anesthesiologist to come to sign our off our chart, maybe we had a ruptured AAA coming to the OR, or they had to come to sign in the case that got started in the OR. They will come to sign in, but for the most part, especially in OB, you ran all the epidurals at night. You would throw the paperwork under the door for the attending to sign off in the morning.
It was a very autonomous way to practice anesthesia in the middle of the night with you and your counterpart running the main OR and OB. It was fun and hard. It was a lot of work. I’m not going to lie. Even when you had “downtime,” it would be an hour. You would be anticipating that beeper would go off. You’re like, “What’s coming next?” You would take turns. You would know if they got up for that pager. The next pager would be yours. Your mind would run, “What is it going to be?”
It wasn’t my cup of tea. It stressed me out. I could never get myself to sleep. The way they situated it is weird, looking back. You had to share a room with whoever you were taking calls with. Everyone seemed to snore. I’m like, “Why does every single person, even the skinny petite women I had to sleep with on-call, snore? I cannot sleep and snore.” I was always jealous that they could fall asleep and I was laying there on this plastic pillow sweating to death, “I can’t sleep.”
That was my experience doing 24 hours. Will I ever do it again? Maybe. I never say no to anything. I’m always open. Maybe at some point in my life, I want to do it again, but for now, it works to not do it. In neuro there are craniotomies. You could do sitting cranies, awake cranies, any kind of crani, and a bunch of spines and backs. In general anesthesia, it’s typical gallbladder laparoscopic cases and anything that comes from the ICU. You get some sick patients needing general bowel surgeries. Toxic megacolon comes to mind, which are sick patients.
We have had nec fasc come to the OR multiple times. Those are scary and disturbing cases. In any kind of orthopedic case, a lot of times, you’re doing your regional block for those cases, depending on the facility you work at. At that facility, I did a lot of regional. They typically would assign a CRNA to blocks, meaning you would be the block CRNA that day. You would run the block room. You wouldn’t go to the OR if you had a lineup of nine shoulders. There would be a CRNA in that room doing the nine shoulders, but you would do all the inter-scalene blocks before the patient returns to the OR.
That’s how they organized it. It was a very busy outpatient surgery center with a lot of regional blocks. There’s no way to keep the pace of a five-minute in and out of a room block when you’re doing twenty-some blocks. You have a CRNA designated to do the regional block. I’ve also known facilities that have a CRNA block team. They would go around room-to-room and do TAP blocks, for example, for various cases throughout the OR.
I also am getting ready to work at a place where I know that some CRNAs typically do their blocks before their case. I haven’t experienced that, but I know that’s what I was told happens. If you have a case where you can do a block, you’re welcome to do the block, whether they do that in pre-op or back in the room to be continued. I don’t know because I’m getting ready to start here soon. We will find out what that’s like. You could spend a day doing different types of endoscopy cases.
There are a variety of types of endoscopy cases, but they typically have endo suites that you can go to. They’re either far away from the OR or close to the OR. My experience is when I first started, they had an endoscopy suite that was a little bit further away. They moved it to be closer to the main OR for safety and convenience reasons. Some places have an endoscopy suite. It may or may not be considered offsite. You have urology cases where people are doing prostate cases, kidney stones, or those types of things.
For OB-GYN, it’s any kind of obstetric case where maybe it would be an ectopic pregnancy, some uterine cancer, or something like that. You could do any OB-GYN cases. You have thoracic, which are lobectomies and any case with the lungs. You have vascular cases, which are things like AV fistulas, abdominal aortic aneurysms, and carotids. Carotids are a lot of work. Carotids are hard but fun. You have bariatrics. There may be a Roux-en-Y case. You have offsite, which is interventional radiology, MRI, and those types of cases.
That’s a rundown of the typical. I don’t think I missed anything, but I could have because there’s so much that you can do at one facility that you work at. All those cases I ran off to you, every single one except for the regional, I got all that experience at one facility when I first started as a CRNA. I did every single one of those types of cases other than regional blocks. When I left and moved to be closer to my family, I sought out a position where I would get trained to do regional blocks.
That’s what I did. That was a surgery center. We didn’t do open-heart. We did some peds. The youngest peds we had there was an eight-year-old, but for the most part, it was older teenagers who would come to the surgery center. I wouldn’t call it a pediatric by any means, but since I had some pediatric experience, it was nice to be more familiar with it versus some of the CRNAs I worked with that had never done peds. I had all that experience at one hospital. That was a Level 1 trauma center that I worked at for four and a half years. I got the regional experience.
I’ve spoken about this before. It wasn’t my thing. I wasn’t into the surgery center vibe. I moved on to pediatric anesthesia, which I love. It’s hard and stressful. Don’t get me wrong. Why am I doing this to myself and making my life more stressful? I love the babies. The environment is good to work in. It has been a great place to work. Everyone is happy there. The collaboration and communication are great. I enjoy it. I’m happy at this pediatric hospital. I’m getting ready to take a 1099 position at an adult hospital.
They do hearts, although as a PRN, I don’t anticipate doing open-heart; maybe some EP lab and things like that. We will see how that goes. That’s the place where supposedly the CRNAs who have original experience under their belt can do their regional blocks. I haven’t started yet. I don’t know what that’s going to look like, but the fact that I have that under my belt has allowed me to say, “I’m comfortable with it. I had adequate training. I would be very quick to pick it back up again.”
That’s what I’m trying to let you know. The more you open your horizon as far as experience and skill set, the more you will have opportunities to advance your career in different ways that you may not have ever thought about. That’s the scope of parts of a CRNA. We practice all different types of anesthetics. Let’s go into what it looks like to be an opt-out state versus the opt-in state for a CRNA practice. I told you we didn’t do any regional in my first practice and why was that versus where I’m going, they allow it.
Before I get ahead of myself, let me slow down a little bit. Where I originally practiced out of school was called an ACT model or a direction model. All that centrally means is for billing. They have to have 1 MD anesthesiologist to 4 CRNAs. That’s the ratio that CMS or Centers for Medicaid & Medicare Services for reimbursement. That’s the ratio they had to comply with to get reimbursed. At that facility, we did not do a lot of regional. They started trying to do more, but it wasn’t what the surgeons were accustomed to. They didn’t promote it, unfortunately, where I worked.
Mostly, the physician anesthesiologists were the ones who did the regional blocks there. When I moved to the surgery center, it was a supervision model. A supervision model is a billing thing. We still can practice the way we would always practice, but because of the billing, you can have 1 MD anesthesiologist to over 4 CRNAs. Typically, we would have 2 attendings there for the day and right around 12 or 13 CRNAs. Maybe they’re are 1 to 6 at noon.
A lot of times, they would have one attending lead pre-op because, for the most part, pre-op would be empty other than a few people. They would pass off to one of the CRNAs or the other attending who would mostly be covering PACU at that time. There would only be 1 attending for 10 CRNAs. They had some flexibility in how they staffed. That allowed the attendings to get to work at a decent time all the time. It’s a different model. That’s the supervision model.You should always seek new opportunities because that brings a lot of fulfillment and satisfaction to your career path. Click To Tweet
We have independent practice, which is all CRNAs. You’re utilizing the surgeon, for example. You would be working under that physician, which would be the surgeon, but you wouldn’t have an anesthesiologist per se physician that you would be billed by. You would be doing independent billing as all CRNAs practice. I have never worked at a facility like that. I don’t feel like it’s super common to get facilities like that in my location, but they do exist. They’re not very common, but they’re out there.
Let’s get into the opt-out. What does it mean? If you’re an opt-out state, does it mean you have more independent practices? As far as answering that question, it’s not necessarily. It depends on the facility and how they bill. The opting-out is a billing thing, meaning they freeze the need to have a physician to bill under to get reimbursement through CMS. It depends on the facility and how they go about this. We are making progress in the opt-out states. How many states are opting out of this CMS billing requirement thing? Twenty states are opt-out states.
Maryland did get prescriptive authority for both pre and post-operatively, which is a big deal. I can’t speak to this on a large scale, but I do know that as advanced practice nurses, we are one of the only, for the most part, that does not have prescriptive authority like an acute care NP would have, for example. That has been a longstanding thing. They are making strides. We got prescriptive authority in Maryland. It allows us to prescribe preoperative medications that we’re going to be giving anyway without needing someone to sign off on them.
When I did 24-hour shifts and epidurals overnight, I put in new epidural orders. I did all the orders. Even in the OR and with my open-heart, I would put in order sets all the time. The difference is the attending would have to then get notified or pinged via the electronic chart. He would have to put his finger on a scanner agreeing to the orders that I put in. That’s the hangup versus me being able to do it. That’s where it frees you a little bit. You don’t necessarily need someone to sign off on anything. You have the authority to sign your orders.
I talked about the different ACT models and what you hear them called. That’s the direction model, which is the ratio of 1 to 4. One thing I want to point out with the ACT model is this varies from practice to practice, too, in the sense that emergence can be negotiable as far as when emergence happens. You can technically argue that emergence happens in the operating or recovery rooms. For example, in the first place I worked, it was an ACT model. The attendings had to be there for induction.
I was there for four and a half years. A lot of them knew me very well and trusted me. There would be times when they would be hung up in their room. We would be waiting. If I didn’t feel like I needed someone else there and if I felt very comfortable with what I had going on, knowing it was safe, I would say, “Are you okay if I go ahead and get started?” Nine times out of ten, they would be like, “I’ll be there to sign in.” I would get started.
No matter what practice you practice in, it’s your responsibility to make that judgment call. You have to know what’s safe. You have to anticipate what you need. If you’re getting ready to put a 450-pound person asleep who has severe OSA and you’re like, “I don’t know how I’m going to be able to mask this guy,” you should get a second set of skilled hands at the bedside regardless of what practice model you practice. It comes down to that at the end of the day.
That practice model is a practice model, but you still always routinely provide safe care. If you need a second set of skilled hands, whether that’s a second CRNA, an attending, an AA, or whomever, get them at the bedside with you. At the end of the day, that’s always your responsibility. Don’t say, “Since I’m going to independent practice or a supervision model, even if I know this is going to be a harder start, I’ll do it by myself.” That’s not the right way to go about anything.
There were so many times when I worked at the surgery center and phoned a friend because I’m like, “I need you here. I need more skilled hands at the bedside for this induction because I anticipate X, Y, and Z.” That’s always the key. When you ask for a second set of hands with you, if it’s not the routine, know why you want it so when you ask for it, you can have a good rationale to give them, “I need you here because of X, Y, and Z.” They know what they’re walking into. Make sure you’re doing that.
Even though it was an ACT model, they were in the room relatively shortly after we got started and they would sign in the case. That being said, technically, this all goes back to billing and how they bill, but I’m letting you know that there are variations in how you will see this practiced. There’s the fact that they arrived relatively shortly after and sometimes before I even pushed the propofol. It would be like, “Go ahead and get started.”
We would always preoxygenate since we’re sitting there like, “Can we push the propofol?” We would start pushing the propofol slowly and then mask. You have to use your best judgment but where the direction model can differ is in the wake-up. Where I practiced before routinely, they would not come to the bedside at wake-up. That never happened unless you needed them.
If you needed the attending physician at the bedside for wake-up, that would be your judgment call. Otherwise, they don’t want to hear from you. It was just to take them to PACU and make sure they were happy and comfortable. All is good. That was the norm or standard in the way they practice. There were countless times when I would call them to the bedside because I was questioning whether or not they would fly.
I want to make sure I have another set of skilled eyes laid on them. Maybe you’re having issues throughout the case, and you want to ask questions. You ask questions all the time. If you’re ever questioning something, you should always do your due diligence and get someone else to the bedside to ask these questions. There were cases where we did induction. I didn’t see or talk to my attending the rest of the time. I took over a PACU and saw them for the next case. We kept going.
There were some times when I didn’t need any help or have any questions. My whole day would be like that. They would be there for the induction. I would see them for the next case for the induction and the next case for the induction. That would be all for the most part unless there were any pre-operative issues where they had to notify me of what was coming down the pipeline. That would be most of the communication I’ve had with my attending all day.
There would be other days when I would talk to him in pre-op. We would do the induction and I called them back in the room a couple of different times because something was going on. I would have issues in PACU or say, “I need you over here in PACU.” It varied based on the case and the patient, how much additional support was needed for that patient and the care. Sometimes I had to make sure I did some good handoffs for PACU and to the attending because I anticipated them needing X, Y, and Z in PACU. The attending should know that because he’s the one prescribing for discharge.
It depends. It can vary patient by patient and shift by shift. That’s enough on that. Back to opt-out, this all has to do with billing and how CMS reimburses facilities for care. The ratios have to be as such. The attendings have to make sure they’re there for induction and emergence in a direction model and a supervision model. They don’t have to be there for induction or emergence, but they have to be in the building, available. You have an independent practice where they do not have to be in the building at all; you don’t have to have an attending anesthesiologist hired in the facility.
You’re working under the physician’s license of the surgeon or the medical group itself. That’s all opting-out means. It’s giving the facility more options as far as billing, reimbursement, and taking away some of those red-tape regulations, but the practice is the same. Whether you’re opt-out or opt-in, the practice is the same, but it can differ from facility to facility, and just because you have an opt-out state does not mean you will have an all-independent CRNA practice. It can still vary from facility to facility.
There are some very high medical directive facilities in opt-out states and vice versa. You can have an opt-out state or an opt-in state and still have a lot of autonomy within a facility in an opt-in state. Whether you’re opt-in or out opt-out, it’s facility-dependent. The opt-out gives them more flexibility on how they want to run their facility, but you can still do it either/or. I want to make sure I make that clear as well because a lot of people think, “I’m an opt-in state or an opt-out state so I’ll get to practice independently”. It doesn’t always work like that.
CRNA, AA, And MD: What’s The Difference?
Let’s go over the differences between AAs, CRNAs, and MD anesthesiologists. As a CRNA, you are a nurse first and foremost. You get your Bachelor’s degree. Some CRNA programs will accept an ADN with a Bachelor’s in Science, not all schools, but that is out there. The vast majority do require a BSN degree to pursue CRNA. There are some people who are respiratory therapists. They get their Bachelor’s and go to an accelerated BSN program and then CRNA school.
You’re like, “An RT is a CRNA,” but they still ultimately have to become a nurse. You can’t skip the nursing and ICU experience parts, and just because you were an RT in the ICU does not mean that counts towards your nursing ICU time. You’re going to have to get separate ICU time as an actual nurse. For some odd reason, that comes up every now and then. I’m like, “It doesn’t work like that.” I want to make sure I’m clarifying that.
Ultimately, a CRNA is a nurse. They have ICU experience. The ICU experience can vary to a pretty big degree. You can have people who barely have 1 year of experience and people who have 20 years of experience. You have people who come from the ER, PICU, NICU, MICU, SICU, CTICU, the burn unit, neuro, and all kinds of stuff. It’s a melting pot of ICU experience. It’s cool and empowering that we all have something unique to bring to the table.
Some of the PICU nurses are rock solid in their dosing of medications because they always have a very good understanding of that coming from the PICU. They also see a wide range of pathophysiology between a toddler who’s 2 and a 16-year-old. That’s a strength if you ask me, but not all schools look at the PICU experience. Don’t shoot the messenger, but that’s the way it is. It’s the same thing with the NICU. That’s a very small subset of patients. It’s a narrow range. If I had to pick between NICU and PICU, PICU would probably give you a better range of experience for ICU experience.Don't fear that you barely have ICU experience. You will have strengths and weaknesses, and that's okay because you will build upon those strengths when you start your program. Click To Tweet
That being said, I don’t make the rules whether they take NICU or PICU. Don’t yell at me about it. Research this early and often, so you know what your schools take. Having the ICU experience as a nurse is a big part of our strength when you go into CRNA school because you have a good bedside manner, communication skills, team skills, and this sixth sense that you’ve developed when you know a patient is going to crash. You have a lot to bring to the table, whether you know it or not.
You’re going to feel like a fish out of water when you start CRNA school, but I promise you that you have so much to bring to the table when you enter CRNA school because of your ICU experience. Don’t underestimate that. If you’ve been out of school for a long time, don’t fear that. If you haven’t been out of school for a long time and you barely have ICU experience, don’t fear that. Both of you can thrive in an equal way. You will have strengths and weaknesses. You both will. That’s okay because you’re going to build upon those strengths when you start your program.
That being said, an AA doesn’t have any medical background. I hear some people sometimes criticize people who barely have a year of ICU experience in CRNA school, but I’m like, “You build up on those skills when you’re in school.” Don’t get me wrong. You should get good ICU experience. That’s an important foundation. At the same token, if you get into school with only eight months of ICU experience and by the time you start the program, you’re going to have a year, I don’t see what the big deal is for the most part as long as your application and interview have proven as such that you were rising to the occasion.
I noticed that students, especially those with very little ICU experience, hit the ground running. They do okay. Is it a hard adjustment? Sure. It’s the same thing for the person who has 5 or 6 years of ICU experience. They might not hit some of the skills running. They might be more adept at keeping up with the pace but still have a lot to overcome with the knowledge part because they have been out of school longer. They’re like, “It has been five years since I’ve done chemistry. Now I have to relearn it.”
The person who had gone to school sooner is like, “I got this academic stuff.” It is not a breeze, but they can probably pick up on it quicker. Maybe that’s more their strength or their clinical is a little weaker and vice versa. That being said, AAs don’t have any medical background as far as they have never been a nurse’s aide, an ICU nurse, or anything in the medical field. They have to have a Bachelor’s in anything. It was from Purdue’s website that said it. I wrote it down. You need a Bachelor’s in anything that excites your curiosity.
In AA school, no medical work requirement is needed. You take the MCAT or GRE, but they do have prereqs if you have a Bachelor’s in arts and crafts. When they say that, I’m not sure what they mean because then they still have science prereq. If you have a Bachelor’s in anything that excites your creativity, you’re still going to have to then go take science prereqs, which include physics, math, and a lot of the prereqs that you would get in your ADN. They also include physics and math, where some ADNs don’t have physics or math as a requirement for that.
They require a B minus or better for all those science courses, where CRNA schools require a B or better. That’s something to think about as well. You might be thinking, “That’s not fair.” It’s a nice thing that we’re a little bit harder because there’s more power to us. That’s the difference between an AA and a CRNA. As far as practice goes, they train the way we do. They go through clinical and complete a Master’s degree. It’s similar to how we used to do it. Now we’re a DNP program.
They went through very similar training. It was done under the physician anesthesiologist. They’re trained by anesthesiologists and physicians, whereas we’re trained by other CRNAs, physicians, and clinical too. Don’t get me wrong, most of our lectures and clinical coursework are done by CRNAs versus done through a medical school. Practice-wise, they’re doing everything that we do as CRNAs, meaning they do hearts, OB, and regional.
That being said, in my time and exposure to working with AAs, there are some facilities that limit what they do, meaning some facilities don’t let them go to OB, do open-heart or peds, but some do. It depends on the facility as far as what their scope of practice is but, for the most part, they function the way a CRNA does in all the different types of cases and skills. They can do A-lines and central lines as long as they’re proficient at it like a CRNA.
That also being said, they can only practice in 14 or 15 states. They’re not fully recognized in all the states as anesthesia providers. That’s something to also think about. They also don’t have any prescriptive authority. They’re also required to always work under the direction of the attending. I talked about the direction model and supervision model. AAs always work at a direction model. They always work a 1 to 4 ratio. They can never be higher than a 1 to 4 ratio. The hospitals can’t get reimbursed to have AAs if the ratio ever changes from that.
In supervision models and independent practice, you don’t find AAs. That’s unique to CRNAs. That explains that. The next thing that I’ll cover is the MD physician anesthesiologist. We all know that they’re going to med school and have four years of residency, three years of which are anesthesia-based. Out of the 4 years, they have 3 years that are covering anesthesia school. Technically, the DNP portion is extending our program out a little bit, but you also practice anesthesia for three years to get your DNP.
Out of that residency, they spend 4 to 6 months, depending on the program, in the ICU. Their ICU experience is only 4 to 6 months, whereas a lot of us have at least a year, if not more, of ICU experience. The ICU experience is vital. We go into anesthesia school having the most exposure to ICU. That’s a huge strength of a CRNA. Technically, if you look at the time, for example, on AA, if you’ve done it, meaning if you get your Bachelor’s in Science, you don’t have to do all those prereqs.
I’m not sure how long that would take otherwise, but if you look at a 4-year Bachelor’s plus a 2-year Master’s, you’re looking at 6 years. I don’t know whether you had your Bachelor’s and all the sciences done that it would speed the process. If you didn’t, then taking those prereqs would slow it down. You’re looking at how the fastest path to AA is six years. The fastest path to becoming an attending anesthesiologist is twelve years if you consider a BS in Science and med school.
A Bachelor’s in Science and med school residency is three years of anesthesia, which is twelve years. Twelve years is the fast track to becoming an attending anesthesiologist. You have a CRNA, which is a BSN. It’s 1 to 3 years of ICU. The average is three. That equals eight years. It’s 6, 8, and 12. The average path to CRNA is more like ten years because a lot of people are not getting their BSN in four years. A lot of times, they do their ADN plus their BSN. I’m looking at the fastest track if you got your BSN, went to the ICU, and spent three years there.
That would be the fastest path to CRNA. You would have three years of grad school. The quickest pathway for a CRNA averages ten years. The reason why that’s different or fluctuates is that the ICU experience can vary. I hope that clarifies the different pathways to becoming a CRNA and how we practice as a CRNA. The opting-out is the billing thing. Whether you’re in a direction model or supervision model, your practice is the same. The only difference is whether you have someone there at wake-up or don’t and whether you have someone there for induction or don’t.
At the end of the day, you get someone there for induction or wake-up if you need them anyway. You will always have a resource person, perhaps that’s a fellow CRNA. You always use your judgment as a CRNA to know whether you need an additional set of skilled hands. I hope you enjoyed this episode. I will see you. Thank you very much. I want to thank you personally for being loyal readers and tuning in. I appreciate you and the reviews. I read them all. Thank you so much. We will see you.
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