The journey to becoming a CRNA starts with picking the right programs for you. However, this is not an easy task. Some often find themselves wondering which ones to pick or even how to begin the vetting process. In this episode, Jenny Finnell brings back to the show Richard Wilson, MNA, CRNA to help. As CSPA’s expert contributor and with 13 years of being a faculty member under his belt, Richard is very well-versed in these programs and what they can offer to their students. How should you pick your school? What are the important things to know about your programs? What are the different aspects to consider when applying? Join this conversation as Richard shares his expert contributor point of view!
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How To Pick Your CRNA Program With Richard Wilson, MNA, CRNA
We have a special guest that’s coming back to the show, my colleague, Richard Wilson, who is also a program faculty member for many years. He also happens to be the show’s expert contributor. We have worked closely now since probably about October of 2020. He’s a wealth of information. He genuinely cares for you and wants to help you succeed. Welcome back, Richard, to the show. I’m so excited to have you.
Thank you, Jenny. I’m glad to be here. It has been a while. I was thinking that when I looked at my calendar on some things. I love being here and being a part of the show. The environment that you have created is awesome. All of that’s going on, and the people that we see are being helped to get into anesthesia school. It’s a wonderful thing. I’m glad to be a part of it and that you invited me back to join you again.
What we are going to talk about is a lot of you may be in the stage where you are trying to decide what schools to apply to and you are like, “How do I pick what school? What’s important to know about my programs?” Essentially, we are going to discuss how to pick your CRNA programs and some of the different aspects of selecting the schools that you are going to be applying to, all from an expert contributor’s point of view.
Richard has been many years of being a faculty member experience. He’s very well versed in CRNA programs and what they can offer their students. I’m excited to bring this topic to you with Richard here to go over things to think about. What would be the starting point when students are starting to say, “I can go anywhere in the entire country of the United States?” You can’t train out of this country for anesthesia for CRNA but what would be one of the first things that you would think students would start their CRNA school search on?
I have been doing this for years. I’ve served on the committee for our admissions probably every single year. I chaired it for a number of years. It has been interesting to see the way that it has morphed over the years, especially with social media interactions of how people choose schools and find out information about all the nurse anesthesia schools. You and I talked before that there are 127 programs across the nation. All have different aspects to them, whether it is in a lot of the topics, we will talk about like curriculum design, clinical experience, cost, and location. You name it. There are many factors that go into it.
Years ago, when I was looking at anesthesia schools, you primarily looked at what was close to you, what was affordable, and where you were going to have to move to. Some of these things are still considered but there is so much more that goes into it now because of social media, the internet, and all the information that’s being presented on them. We are seeing way more factors than we used to know about years ago.
When people start looking at nurse anesthesia programs to start considering, “What are the major factors that I want to do or look at to narrow my field down from that 127,” you are not applying to 127 programs is going to be the fact that let’s look at location and price. Those are the two primary things that people look at. I would offer an adventure to be cautious about that because location and price are not everything but I know within the ramps of where we sit and with all the applicants that we are getting now that location and price are going to be part of what is going to drive somebody to go towards certain schools.
As we look at location and price, the things that we need to talk about are, where is it located? What do you want to look at in a location? Is it near you? It’s because you need to stay near home, there’s family here that can provide a good support system for you, or that your husband or wife has a position in this area. You have kids that are in school in that area, and you can’t uproot and go anywhere across the nation. Those are things that come into factor there.
Let’s go back to what you were talking about and say that you’ve got that Utopia situation where you can move anywhere across the nation you want to move. There are no limitations to you at all, whether you’ve got family, you don’t have a family or whatever it is. You can go anywhere across the nation. You need to start looking at the location of where you want to be. Is this a good school that has great clinical experience, good curriculum design, and numbers when you look at the attrition rate and board pass rates? All of those intangibles that come along with that.
In that program, does it have that that’s going to make you successful and that you are looking for in a successful program? The other aspect of location is this. Where do you want to end up in the long run? Maybe you are from South Carolina like I am but yet I want to be in the Ohio area and live up there. I can go anywhere. Why not try to look at schools in Ohio because programs were started? Let’s go back to the history of some programs.
When you look at the reason that a lot of these programs were started and you look at them being hospital-based anesthesia programs, the vast majority of them were brought about for the fact that they wanted to staff their operating rooms. The easy way to do that was to train them. Therefore, once you train them, you could recruit them while they were training. Train them in your style so that they could come work at your facility in the long run. If they like what they saw while they were training there with you, they could recruit you.
We talk about it being a 27-month or a 36-month interview when you are in anesthesia school at that facility but not only are they interviewing you during that time. You are interviewing them. If it is an area you think you want to work in again in the long run, why not apply to that area? You are training there. You get to see what the facility is like. You get to see the town, the state or whatever the environment is like in that entire area and decide whether that’s where you want to be or not.
We do know a number of programs that if you train in their area, they are more likely going to be willing to hire you because they have seen you and know what they are getting than hiring somebody maybe from West Virginia, California, Michigan or whatever it may be because they have never seen that individual before. The location could be big, not just for you and the program that you are attaining but for the area also.
I’ve even heard that some programs can be selective, sometimes preferring applicants who are local, meaning they are from the area they are applying because they also know that they are more likely to stay and take jobs in the area, which is what these hospitals desire but that doesn’t mean that you shouldn’t branch out and try other areas. I’m not saying that at all. Be cognizant of that and aware that it could be something you run into. Do you have anything to say about that?
[bctt tweet=”Be cautious when choosing your school and program because location and price are not everything.” via=”no”]
When you look at that part of it in itself, one thing to ask these programs or if they’ve got it posted on their websites, which some people will do maps with the dots on that show where all of their recent graduates have gone is to look and see. You are going to see a cluster right around the university or a hospital that is the primary training site because a lot of applicants that go into these nurse anesthesia programs do stay in local areas but you want to see.
Do they have a splattering of those dots all across the nation, which is showing that they are doing a great job of training overall if they are able to place them all across the nation? They are focused on training students that are going to go out, be great practitioners, and go all across the nation versus just trying to train for a local hospital.
That’s key when you are looking at the location, talking about facilities, and looking at people local what they do. The facilities are investing money and time in your training as a nurse anesthesia student or nurse anesthesia resident. They do want to know that they are going to get an ROI, Return on Investment by doing that.
They do want to recruit you and get a lot of people to stay in that area but you can also tell how well the program is by looking at where they send people post-grad employment. Are they sending a number of them all across the nation to go work? That is something you can ask online in these social media venues that we have. There’s plenty of information out there like that. You can ask about the programs. They probably can give you an idea of where everybody is going.
Also, you referenced the price aspect too. For those of you who missed an episode, I do have a guide if you want a list of about 60 CRNA schools that are under $100,000. There are only about 50 students schools that are under $100,000 and about 10 schools under $60,000. When it comes to price, since location and price are two things that a lot of people initially started thinking about, myself included when I was looking at CRNA schools, why are some programs so much more than others? Do you have any explanation and then also what the differences you would get from a program?
There are so many factors that go into the price, unfortunately, because we live in a mindset where we do think about price, especially in our society where we are seeing gas prices approaching. Here in the Southeast, $4.25 is what I’m saying. We were laughing when we remembered it being $0.98 to get a gallon of gas. There are so many different factors that go into it. Unfortunately, we are only thinking, “This is the cost of it,” but you’ve got to think about a couple of different things when you look at the price. One, where is it based? Is it a public university or a private health sector?
A number of years ago, it was about in the ’90s that the Council on Accreditation required that all programs become affiliated with a university. They were all hospital-based before that but within about the ’90s or so, the Council on Accreditation said, “You have to be affiliated with a university.” In the end, a lot of the hospital-based programs went out and started seeking what university and what department in that university they wanted to be a part of.
You have some that are part of public health, some that are part of nursing, and some that are in a school of medicine. It depends on what was close to that facility and who they decided to partner with. Was it a state university or a private school? Was it an Ivy League school versus a state university? It all depends. You are also looking at in-state versus out-of-state tuition because it’s a university. They have to do this. A lot of people wonder why if did you dive into the aspects of it.
The state universities receive state funding from the government. Therefore, they do offer a discount to get more of its constituents or state citizens in that university and charge a little bit more for those that come out of state because we are paying state taxes that go towards that state university. When these hospitals partnered, who did they partner with? Do they partner with the state university or the private Ivy League school?
That’s going to make a difference in what the tuition costs are for the program. There are also clinical fees associated with some of the universities and hospitals, such as if university X partners with hospital Y, in one state, that hospital may be trying to recoup some of its cost for education, simulation supplies, and so forth. They require the university to pay a clinical fee to them, which is then passed along to the students. Some do not.
That’s one of the different aspects of costs that go into the programs. When you look at also the supplies, precordial stethoscopes, books, computer programs for tracking clinical cases, and so on, there are all of these additive costs that can go in based on which facility or university you are training at. There are so many different factors that go into what the price of that program is going to be. The one thing that we haven’t even touched on with price is the cost of living in that area.
That’s an additional cost because the university may say that it is a lower education. It may be in that top 50 that you were speaking about. The cost of living is high in that area. That’s got to be also considered with the price for the program. A lot of times, we look at tuition and then the additional costs like clinical fees, books, and so forth but we forget to add in there that cost of living, which can make a huge difference for your program.
I love that you mentioned that. I’m so glad you did. I want to point out too that cost is only one factor. This is an investment. Going back for CRNA is a very smart investment. You will earn your money back 50 to 100 times over. Nonetheless, it’s a hard thing to swallow when you may be entering school and already don’t have a lot of savings.
A lot of people ask me, “How am I supposed to pay for my living expenses when I’m not working? How am I going to get enough loans to cover both tuition and my cost of living?” I have a whole other episode on this too. There are ways to get additional money to help cover your living expenses. As Richard pointed out, consider this. Don’t just pick the cheapest school. Consider what it would cost to live in that city and things like that.
Let’s touch on that investment part. I love the word investment because I always think about how going to school should be an investment. None of us are going back to school to toss money to a university just to say, “We did it.” There’s always an investment piece we need to look at, which is always ROI, Return on Investment. Everything goes back to Return on Investment. No matter what we do in life, it goes back to that ROI. When you look at a nursing salary, I’m going to go back to the days of where we were pre-COVID before we got into the nursing salaries.
Many people were traveling and being where they were. That’s wonderful that the nurses are able to get what they are getting out of it. A lot of them are probably getting what they are finally worth versus what was in the past. You look at somewhere around the nation. There was a $75,000 salary for a nurse on the yearly side of it. That’s on the upper end in the timeframe I’m talking about. You then are coming out with a salary when you graduate, and the minimum in a lot of these places is $150,000-ish.
You are doubling your salary over a year. You are going to possibly go into debt and take a hit on some things. What you have to look at is this, “In the short-term, it’s going to hurt me, and it’s not going to be fun but in the long run, over the 10, 20, to 30 years, I’m going to be putting in this profession, it’s going to be well worth what I have invested in this.” There are private loans out there.
The university will get your loans. You will work with a financial aid officer. They will be wonderful in finding you all the low-interest loans that they can get you and so forth. You can either go work at some of the critical access hospitals, and some of the places will wipe those loans you have clean when you come out. It varies from year-to-year. It depends on the market, where they will pay your tuition, allowance cost, and some of the facilities or they will give you stipends, bonuses, and so forth.
None of that is predictable from year to year because it is a volatile network that we are working in. It’s a volatile area that is up and down. I have been practicing for years. I’m in about my 3rd or 4th wave of all of this that I’m seeing. It varies but I always tell people, “Don’t focus on the money aspect of it or you would never go back to school. If you focus on that aspect of it, you would never go back to school.”
I’ve never heard anybody say, “I can’t wait to go into debt.” That’s the way you look at it. Here’s the thing. The ROI is unbelievable. It’s not just the money aspect of it. It’s nice to have a salary of what we have but it’s also the flexibility that I get in some of my scenarios. It’s the ability to have autonomous practice. The area that I can have is the ability of a better work-life balance at times. There’s so much that comes not just on the financial side but overall when you look at the impact.
It truly is an investment. However, do know you are going into debt. One bit of advice I will give everybody is to remember as we talk about school loans. This may be another great episode down the road if you ever have me back again. We talk about how they determine student loans and how you do a financial. Natalie does a lot of stuff for you but financially, thinking about it because student loans are not based on the fact that I own a house or a boat on the lake and two cars.
It’s based on the fact that I came out of undergrad, and I’m going straight into graduate school. I may have to make some alterations to my lifestyle. Let’s get back to the cost of living for where you are going to school. You need to look at that because you might have to make some modifications to your lifestyle. If you are going to be tempted to go out and to the lake all the time, and do all this other stuff, maybe you are somewhere you don’t want to go to school or stay away from so that you can save some money while you are going through school.
Some schools even build the cost of housing into tuition for clinical sites, for example, and some don’t. Finding this out ahead of time is also key. There are students who travel to Ohio for clinical where I work, from Arizona and California. They oftentimes have to try on their own and find their long-term stay Airbnbs. A lot of the CRNAs and attendings I work with rent out houses around the area for the students for that reason to try to help them. The cost of living is big.
If you want to pick an area to go to school and then hopefully work afterward, consider not only what the cost of this schooling is but also what’s the average new CRNA salary in that area. If you are spending a lot on school and then you want to go work in the area where the salary of a new CRNA is not so high, think about that versus if you spend a lot on your schooling. You know you are going to go work in a city where CRNAs are paid very high compared to the average, and Montana is one of them, then spend $200,000 on your education and make $250,000 as a new grad CRNA in Montana. It’s something to think about.
I have a very simplistic mind. I have to think about things simplistically to understand my mind. You bring up a great point. It’s like taking money to a bank. This is the way I look at the Return on Investment. As you are talking about salaries, where you want to work, it’s like taking $20,000 to a bank. Let’s go with $100,000 because you mentioned that number when you were talking to me about the 50 schools and so forth.
Let’s take $100,000, “I’m going to invest $100,000 over three years. However, I know that when I invest $100,000 over three years, I’m only going to get a 2% increase over those three years versus a 7% increase over those three years in my investment.” It’s common sense. What are most people going to do? If they are looking at the financial return on the investment side, they are going to put it in the account that’s going to get 7% versus the account that’s going to give them 2%.
You’ve got to think about it, “How much money am I investing into this?” It is the tuition dollars, the cost of living, and whatever that you are going into debt for to go to school. What is that ROI, Return on Investment? What is that salary that I’m going to get in the long run? You have to compare those because you may go to a school that only costs you $60,000 and only get a high salary at the very end but it may not be as high as the salary that’s going to cost you $150,000 to go to school. You’ve got to see what the balance is and what works out well.
It’s something extra to think about. This is where schools can differ probably the most. It’s so hard and unpredictable because clinical sites change a lot. Let’s talk about the clinical aspects of schools and how they can vary depending on locations in the school.
[bctt tweet=”There are all of these additive costs that can go based on which facility or university you’re training at. There are so many different factors that go into what the price of that program is going to be.” via=”no”]
It’s going to vary on the state, your region of the United States, the university that you are at and their primary training site, the affiliated sites, the faculty, and the people overseeing their clinical sites. Have I given you enough factors there to consider?
In one city alone, you can have different practices. It’s so variable.
The biggest thing too that we are seeing something for people to consider is all these mergers we are seeing within these health facilities. What we are looking at with some of them is when they merge, they want to merge their practices, guidelines, policies, procedures, the type of anesthetic they provide, and the model that they are using. That has an impact because if you are looking at a university XYZ and the only facilities they go to are within the same health system.
You need to find out. Is there any variation in which you are learning? There may be because we do still see facilities that are located within the same health system. They are doing practices completely differently. That’s great. There’s nothing wrong with that but we see some that are not. You want to make sure that if you are going to those facilities or universities that you are seeing that they go to outside facilities.
For example, we do have two large Level 1 trauma centers as part of our program. They are both located within the same healthcare system. There are some things that are very similar or pretty much exact across a lot of our facilities. We may have 2 Level 1 trauma centers and probably 8-ish small hospitals associated with ours. Our students go to a lot of those but because of that, we have also created opportunities outside of our system where they see different anesthetics being provided, whether it is regional anesthetics, CRNA-only practices or whatever it may be.
You want to see that the facilities have done that, and those universities have created that type of scenario where you may see all kinds of stuff. Here’s the thing. I am as guilty as anybody else. You know that the mindset I have of what I’m thinking about where I want to go work is the best thing ever. We all get into that. “I know what I want to do. This is the best decision.” When you are down the road, something slaps us in the face or the back of the head and says, “This was not the right decision. You don’t want to go work in Ohio. You want to go work in Michigan.”
I need to be trained so I can go work anywhere. That’s what you want to see with these facilities. Are they training you to go work anywhere? That doesn’t mean that you weren’t going to get 100 hearts, 100 peripheral neuro blockades or 100 cases with pedes. It means you’ve had experience with it. Academically, they have trained you for all of that. Clinically, they would give you some good experiences with it that you can build on, whether it’s a workshop, a more clinical experience within the facility you get hired at or whatever it may be.
That’s one of the things you look at with the training facilities and clinical sites. They can vary. It can vary in a three-year program from the time you get into it to the time you’ve graduated. Within some years, we have added 1 to 2 more additional clinical sites that we have our students go to. We may get rid of a site or two based on the experiences that each one offers as we start to look at what unique experiences we can create. For half of our students, it’s different than what they are going to get at their primary training site.
Would you say your students, on average rotate to maybe four different hospitals total or 4 to 6? Does it depend?
It will depend but within our program, we are fifteen months into the Master’s level. We converted over to Doctoral. They are starting to go into the clinical and Doctoral sides. There will be two years-plus straight up in the clinical side that they may hit ten facilities overall. We may do anywhere between 6 to 10 facilities.
I like that, though. I rotated six. I’ve also worked at a facility with a program affiliated with it. Mostly, those students only train there and in that hospital setting for the most part. A lot of them were pretty much direct hires into our system. They knew the system well. For example, I hardly trained there. I only trained there for my OB experience. That was it. Most of my clinical training was at a different hospital. For example, those CRNAs have never seen hypotensive anesthesia techniques with Cardene.
I rotated through an ortho surgery center that routinely practiced that. It wasn’t my favorite, to say the least but nonetheless, I was exposed to it, mixing up, and diluting Cardene. I’m using it essentially to bring the blood pressure down to lessen bleeding. I was very comfortable using it. I needed it in a pinch. I had a patient who was hemorrhaging. He was bleeding out back into the brain after a tumor removal for crani.
I remember doing it. The students said, “What are you doing?” I’m like, “It’s okay. I know what I’m doing. It’s going to get their blood pressure down. Their blood pressure is 200. I have to get it down.” It was one of those examples of how they didn’t train that way. They thought it was an unsafe method but it wasn’t. I knew how to do it safely but they had never been exposed to it. You do get some different experiences depending on where you train. It’s nice. It adds more tools to your toolbox essentially.
You know my background. For those that don’t, I was fortunate enough to open up our satellite campus located about 100 miles or so from our primary campus. When I opened it there, I had six students on campus. I’m excited. We expanded to thirteen. That’s nice. We have been moving up over the years. We first started with six students. Our students went to the same place and stayed within the same healthcare system in our area. They didn’t see a lot of variety at that point. They got great training. Don’t get me wrong. They saw a lot of variety of cases.
We can talk about that because I want to talk about the variety of cases and how clinical sites set that up. That’s interesting, and the different ways that I’ve found out and learned about how people do that. When you look at it, they were only getting a certain type of anesthetic that was being provided, they had to grow on their own a little bit more than some others did. That was one thing that stuck out. We started looking at how we can expand that out.
That’s what you will see a lot of programs do. That’s why you see them vary so much because they will get feedback from their students at the end of every year and figure it out, “What’s working for us? What’s not working for us?” They are good programs as long as they are trying to remain active and vigilant in what they do. We will start by saying, “We don’t need to have this X place because they are going there and getting the exact experience they get somewhere else.”
I’ve had this place in Colorado call me and say that they want our students out there. We are able to work something out, and they are going to get a very unique experience. Let’s look at doing that and giving them a better variety of cases, not just cases but also thought processes of how they do it. You go out because we all say we are going to stay up on continued education and be wonderful with that aspect of it but we get busy. We get to work 40 hours and then 15 to 16 hours because we see how nice the overtime pay is and how easy it is to pick it up at times.
We don’t stay active in all of the readings and processes we need to be. Having those different experiences that you can pull from your training is going to be huge when you go. You know this as well as I do. You have done this. You go join another facility to work maybe as a 1099-er or as a PRNer. You have to transfer facilities because you don’t like what’s going on at this one and you want to move to another facility, or another opportunity has come up. You want to feel comfortable that you can walk out of place 1 into place 2 and be okay with it.
There’s the fact that you offer a variety of clinical sites. I didn’t know this back when I was looking at CRNA schools but I also enjoy that aspect of my training. That being said, even in the program I was referring to, most of the students trained in one facility get good experience. I’ve never seen anything like their open-heart training. I had an open heart in this facility for a lot of years. Those students were rock stars in open-heart because we had such good open-heart surgeons.
That being said, another difference I noticed too when I started working there was no one used to laud it. When I trained as a student, a lot of us got candy. Everyone got at least a milligram, if not more. That was their narcotic of choice. I remember when I first started working there as a new grad and using it. They are like, “What are you doing?” I’m like, “What do you mean? I’m doing what’s best for the patient.”
It was interesting to me because even the attendings were not comfortable with giving Dilaudid during an anesthetic versus they were wanting me to sit for the PACU, for example, only. It wasn’t how I was trained. It’s the fact that I’m comfortable with that technique now. I work at a pedes hospital. We routinely use Dilaudid during a case. 5 mgs per kilo is a great dose. It’s not going to usually burn you.
It’s knowing these things. It’s nice to have this familiarity with it that maybe I wouldn’t have had if I only trained there but there are a lot of strengths to that facility as well. To me, it’s not a cut-and-dry decision. Take it for what it’s worth, knowing that you are going to have a variety of good and bad with all clinical training aspects. You are never going to have the best of everything. I had terrible open-heart and OB rotations when I was in school to the point where I remember being in tears and thinking I would never make it as a CRNA doing open-heart because that was what I wanted to do.
I had five hearts and got the bare minimum that I needed to sit for boards. I felt upset about that. The reality is six months after graduation, I joined an open-heart team. They did train me. I remember feeling, “It’s easier to train as a CRNA than it was as a student.” Don’t limit yourself in your practice. Just because you didn’t get the best clinical experience as a student, it does not mean that you can’t seek out self-growth while you are practicing as a CRNA.
There are good things I want to touch on there that I thought you did a great job of mentioning. Let’s look at one, talking about clinical experiences and what you are getting at the facilities. Second, I do want to talk about being active in understanding and using different methods while you are in your training process and looking at facilities that let you do that. Let’s look at, first of all, the rotation. I say rotations because that’s what I’m used to in our program.
What everybody may not understand, and as a little bit of further background, you know how I like to educate and do some further background knowledge, is understanding where everything comes from in decision processes. When you look at how many cases, you got a minimum of five open-heart cases. That’s all you needed for graduation. The Council on Accreditation looks at the fact that to be considered proficient in certain areas, they want you to get some experience.
We know that when you look at what the Council on Accreditation requires, it’s five open-heart cases, X amount of pediatrics under one year old, and X amount of peripheral nerve blocks. They have all of these categories that you have to meet. What that means is you can pass the courses and have a 4.0 in your degree. However, if you don’t meet all of these minimum standards for case numbers, then you don’t get to take boards. You’ve got a degree, $100,000 worth of debt, and nothing to go along with it.
There we go. You want to make sure that you are getting plenty of experience. One thing to look at is the total case numbers, on average. The Council on Accreditation wants to require everybody and all programs to post on their websites how many cases on average, their students are getting each year, 650, I believe, is the average minimum number. You’ve got a certain amount of open-hearts and intrathoracic cases that are lungs, pediatrics, and orthopedics.
There are so many different factors that go into this. We would have to go into a four-hour episode to explain it. I tried to explain it to my students when I was going through Meditrek’s documentation on clinical reporting. It takes forever. We won’t get into all of that but here’s what you need to know and where I want to focus. Some programs have specialty rotations, and some don’t. That doesn’t say that one is better than the other but it gives you an aspect to think about when you are doing clinical training.
[bctt tweet=”Going to school should be an investment. None of us are really going back to school to toss money to a university just to say we did it. There’s always an investment piece we need to look at.” via=”no”]
For example, you’ve got a rotation, and you are trying to get hearts. Your rotation for four weeks focuses on nothing but hearts, peripheral nerve blocks or pediatrics. Instead of getting the minimum number, you are going to get more than that. Let’s say you are doing, on average, one heart a day. You’ve got 5 days a week for 4 days during that week that you are doing them on that schedule. There are 20 hearts right there in that 1 month. The cool thing about that is the repetitiveness of it.
If you are going 5 hearts and getting them over an 18-month period, you are not going to remember much of that. You are going to remember enough to matter and help somebody but you are not going to feel comfortable coming out and doing one. Let’s say you do that and get called in the middle of the night on a call rotation or a night shift. They say, “I’ve got an open thoracic abdominal aortic aneurysm coming in. I need you.”
You are going to go, “You don’t. You need a prayer and a hope.” What you can look at is, if you’ve done those twenty, you get called in a month later, you may feel comfortable going in there and doing that procedure, that emergency valve that comes in or the pediatric case if that has been a specialty that you focused on.
You’ve done 80 of that pediatrics in a month, you know how many you can do in a day. You can do about ten in a day sometimes. One thing to look at is how many of those specialty numbers are they getting, not just how many numbers overall but how many of those specialty numbers because that repetitiveness makes it stick in your mind and become comfortable with it versus doing it over an eighteen-month period a minimum number of times.
What I’ve noticed is not all schools report that. They will say the average number of cases, which I would say you average for all schools across the entire countries almost double 650. It’s right around 1,000 to 1200. That’s what I most commonly see. Some of our students get 1,800 cases. I don’t even know how that’s possible but it can vary. When you are looking at all these specialty requirements, is that something that students could ask to see?
You can ask about the rotations or the clinical experience with specialties. You can ask in a vague way and say, “How do you get your clinical specialty experiences? What format is that in and so forth?” More than likely, they are going to explain that to you or share that with you. It’s not anything that COA requires. Mainly, the only thing the COA requires is the total number.
When I say COA, that’s the Council on Accreditation. They require the total numbers to be represented out there. They are things that you can dive into with either the faculty, post on forums, or whatever it may be, and try to find out a little bit. You won’t find out every grain of every detail but you may find out enough to give you an idea of what these programs focus on.
A good open-house question, for example, is a good thing to ask. Interestingly, you said not all schools have specialty rotations. At least from my experience, they all do them a little bit differently. I had a three-month pedes rotation but the rest of my specialties like OB, hearts, and peripheral nerve blocks were just a month. In that one-month timeframe, sometimes it’s hit or miss with how much experience you get.
What I thought was unique with the other program that I didn’t go to but that I worked at the facility where the students went to was the very last 3 to 4 months of their clinical training. They got to pick, meaning, “What do you need the most? We will help you get it.” We uniquely worked at the facility that did pedes. We did OB, hearts, neuro, and all kinds of stuff. The only thing we didn’t do a lot of was regional. The students got to essentially say, “I didn’t get my heart and OB numbers. I need more epidurals.” We would work with those students to make sure they had more experience in those areas. I thought was a nice feature.
Looking at the rotations, not all of them do rotations. I have found out that across the nation, we have 127 programs. There are a lot of varying aspects of it but some say, “When you go to facility X, they do a lot of open-hearts.” If you can get into those, try to get as many as you can get but it’s not a specific rotation. Some facilities say, “When we put you on the schedule there, that facility knows that you are getting an open heart this day unless there’s not one.”
Therefore, that is the focus of when you get there. It’s a different aspect or thought process in that. It’s something to think about when you look at that. There are some. I love those programs. They do a great job of it when they say, “We’ve got about our last three months, and then you can go to work.” Within their last three months, most people know where they are going to be employed and what practice they are going to have afterward. They can come back and say it.
I love when my students come to do this with me. I had one do it. It’s so exciting. I never thought she would do this. She turned into a pediatric CRNA, “I figured I would make you proud.” It scared her to start with but she came to me. It was hilarious. I have to tell you the story. She came to me and was like, “I love doing pedia.” She was about 5 to 6 months away from graduation. She was like, “This has become a passion of mine.” I was like, “Are you telling me you are going to do pediatrics when you graduate?”
She was already hired in a position outside of our facility, where she was primarily training. I said, “Are you telling me you are going to do pediatrics when you get to that facility?” She was like, “No.” I said, “Are you telling me you are going?” She was like, “Yes, I’m going to do pediatrics.” I was like, “I’m glad you said that.” I worked her into an additional month of pediatrics before she graduated, pulled her off in general, and put her in an additional month of peds so that she could feel comfortable in the facility.
Facilities love that because all that does is get you better trained and off the ground and running quicker. The CRNAs love it because it makes them feel comfortable. Do you know who pays and benefits from that in the long run? It’s the patients. They benefit because everybody is comfortable with them. Some of those places say, “You are going to do a lot of OB calls. You’ve only got ten epidurals while you were on your OB rotation. Go up there and do some more epidurals and focus on that.”
Those are the good and very student-focused programs where they can say, “It’s not about you going in here and doing an eight-hour day to check it off.” You come and say, “I’m struggling with intubations.” I will tell you, “You’ve got no cases. Let’s go do nothing but intubation. That’s all we are going to do. We will enter from room to room and stand up at the board. Every CRNA that walks by that doesn’t have a student already with them. We are going to ask them if they are doing intubation and following them.”
That’s great for the student and the patient because, ultimately, you want to come out as best prepared as possible. We have a lot we are going to cover in this episode. I don’t know if we are going to get to it all but let’s briefly touch on the curriculum a little bit and how it can differ. For the most part, you are going to learn pretty standard stuff. Would you say you see a lot of variation in the curriculum?
There are going to be core concepts that are associated with anesthesia that you are going to have to learn. It’s like the nursing program you went to. There is a Council on Accreditation that oversees the overall curriculum. You have to meet those standards of the curriculum and show that these specific objectives and quality metrics have been met. There’s going to be a standard that you see. There will be variation in how they do it. How do you lead your leadership course? How do you teach your health informatics course? How do you cover legal, ethics, and wellness?
All of that can be covered and handled in different ways. How is the scholarly project overall seen and communicated to the students? How is it managed? That stuff can vary. When you get through basic anesthesia concepts, your pathophysiology, the medications that we use within anesthesia, and the pharmacology aspect of it, most of that is going to be standard in what gets covered overall but there are going to be some variations in the curriculum. It’s not just in the course but it’s also the way the curriculum is laid out.
How many courses do you have per semester? How does that affect the clinical hours that you are going to get each semester and the total number of clinical hours that you are going to gain within your program? Do you start online or in-person? If you start online, is there going to be faculty support for you while you are online versus if you are a part of the university? That’s going to be the whole design. You have to get in touch with the university people. We know how that goes.
Are you going to have specific faculty members within the nurse anesthesia program that you get to discuss things with? Are they following you the whole time? If the curriculum design is that you are starting online, how many classes are online? Is it going to allow you to work part-time, decreasing the amount of debt that you are going to have overall? Is it going to be a full-time course load online? Therefore, you are not going to have time to work.
There are so many different factors that go into the curriculum, especially when some programs are still Master’s and some are Doctoral. Now that we have moved towards Doctoral for everybody effective immediately, we are going to see some of that narrowed down but within the design, courses, and topics that the Council on Accreditation said you have to have, a health assessment is one of them. It depends on where you are and what the design is going to be.
Let me give you an example. Let’s say you are out of a nursing school, for example. They say, “We’ve already got a health assessment course designed. You can join in with our health assessment course. You don’t have to worry about teaching it. Send your students to us and tuition dollars to cover because we are not going to do it for free.” You send them some money to pay their instructors to teach that course for your students joining in but it’s taught by nursing instructors.
Therefore, they are focusing on health assessment on a nursing end, which you’ve probably already had some of that. It’s just advanced now versus anesthesia. However, let’s say you are out of a school of allied health or public health, a school of medicine, or even a school of nursing that teaches their health assessment course. It’s going to be more anesthesia-focused than generic. That’s how your curriculum design could vary even within programs themselves when they know what big topics they have to teach based on the Council on Accreditation standards.
I’ve even heard of some programs like advanced pharmacology, for example. I’ve heard some students say they are in it with other nurse practitioners. They have their own but I found that odd that they would combine anesthesia with that because ours is so specific.
Unfortunately, when you look at some of those programs, that’s a great point to bring up. I know several that are doing the IPM, Interprofessional Medicine or IPE, Interprofessional Education. When you look at the IPE curriculum, it is designed to try to get professions and degrees in with each other to promote working together in a team. There can be negative aspects or unintended consequences that go along with that.
When you have those courses and universities teaching those courses, I’m not saying that IPE courses are bad overall. See what they are focusing on. For example, if you’ve got a pharmacology program or course and a physiology course being taught, let’s go with the form. In physiology, you can have a lot of overlap. Let’s go with the form where there are a lot of variations and differences between us and nurse practitioners potentially or even other healthcare professionals.
They are teaching the pharmacology aspects of it. How are they teaching this? What are they teaching? That’s something to dive into and see how well that faculty is in with that group. Let’s say it’s out of the school of medicine. You’ve got professionals from a Biomedical Science Doctoral type of degree and the nurse in there. Are they focused a lot on anesthesia?
I know some programs, for example, that are IPEs and pharmacology being taught together but the nurse anesthesia faculty is so ingrained in that course and watching everything that they have pushed for anesthesia focus. These other individuals are being dragged along into understanding what we do. They don’t score as well as we do because it’s our focus. It’s not a focus of theirs but that benefits us because we as nurses are getting pharmacology courses focused on anesthesia, and then everybody else is taking it. You’ve got to see, “Is it a pharmacology course that is generic?” You are joining in with it but you are having to teach a lot of the anesthesia aspects to yourself on the side.
[bctt tweet=”Without successful faculty, you’re not going to be successful in the program.” via=”no”]
I can’t speak highly enough about coming to open houses and trying to find out this information. That’s the best way. I hope someday to have a giant outline map of all this stuff because it is a lot. Not all of it is super clear online but this is the stuff that you can dive into when you go to open houses.
You need to ask a lot at open houses because this varies from year to year. Curriculum designs can change from year to year. I’ve done this in a number of my courses. We have it designed. We have health assessment courses and basic principles of anesthesia courses in one way. We get feedback, see new methods of teaching, proctor things online with the forums, and say, “This is a new technology or method of teaching.” We start moving toward that.
Always check. It may be that the university comes to the program and says, “You are going to let this group teach this course or have them join in because there are some times that we as faculty and even program administrators don’t have the final say in the program.” Sometimes the dean of the medical school, the dean of the school of nursing, or the president of the university says, “I need you because you’re successful to help this program come along. I’m adding them into your courses.” It can vary from year to year. I’m always saying, “Keep checking.” Don’t assume because years ago, that’s how it was that it’s the same tech way. Ask, “Is it the same? Do you still do this?” That way, you can get the pertinent information that is vital for that time when you are trying to make that decision.
Simply, you can ask the question, “How do you structure your anesthesia courses versus your general courses like pharmacology and pathophysiology? Are we learning with mostly an anesthesia cohort? Are we learning combined with nurse practitioners and medical students?” Ask those types of questions if this is the thing that matters to you. Let’s briefly touch on faculty and then maybe the support around faculty with the student body.
The faculty is huge. Without successful faculty, you are not going to be successful in the program because the faculty is going to drop everything. We drive the curriculum, your clinical experience, and the evaluations that you are going to get. There’s so much to the faculty that drives within your program. That’s key. You want to make sure that you are looking at a faculty that has the experience, good thought process, and EI.
You want to make sure that the faculty is looking out for the best interest of students. They need to be student-focused. Let me sit on the student focus briefly. The student focus side does not mean that they are agreeing to do whatever the student says to do. We know how that comes across sometimes. What they are focused on is the success of the student.
We always remind them. They are teaching 30, 10, or 50. Whatever the number of the cohort is, we are having to design everything that’s best for everybody overall who can’t design. I’ve got ten students. I can’t design ten different curriculums and methods of teaching so that we can meet everyone, however that is- on the classroom side of it or the clinical side.
You still want faculty that can say it, though. If Jenny comes to me and needs some personal attention on an academic or a clinical side that I can give that to her, provide that, and see her as an individual and what her struggles are or I can encourage her where she’s doing well, it’s all for that personal support and touch that come along with them.
The faculty is very big in their experiences. If you look at the faculty and you’ve got them from a wide range of ages and experiences of clinical backgrounds, you are going to get a lot of different opinions. That can be good and bad. The bad side of it is that it may confuse you if you are a very Black and White type of person instead of living in the gray area where you either want a yes or a no because you are going to get a lot of different opinions in there.
If you like to gain all of that information, I will acknowledge, figure out, and decipher what’s going to work best or what is great knowledge. That’s going to work well for you when you’ve got all of those different experiences. You want to see that they’ve got enough faculties to matter. What that faculty ratio is? It depends. That’s an answer you hear a lot in anesthesia school.
You want to look and make sure that they’ve got enough faculties. You don’t want 2 faculty members for 100 students but do they have that? Talk to students and ask faculty, “Do you have a student I can follow up with to find out more information about the program.” If they are not willing to share it, that always throws up a red flag for me but maybe they will share.
If they do, talk to that student and ask them, “What is the support? Are your faculties available? They don’t have to be available at midnight or 1:00 in the morning but are they available during most business hours from 7:00 to 5:00? If I do need them for an emergency after hours, will I be able to reach them? Are they going to get back to me and let me know some information?”
That’s what you want to look at in the faculty support area, “How do they support a student that is struggling?” That’s the key question. We all work well in an environment that is great, whether we are students, faculty members, or clinicians, we are in a relationship. We all work well in that aspect where everything is going smoothly and great.
What you need to find out is, “If students are struggling, are they work working well in that environment?” In other words, if a student is struggling clinically, do they work well with that student and offer them opportunities to get back up to speed. If they are struggling academically, what is the process?
Are they checking on them, offering additional study sessions for them, or forwarding them over to other students that can help them study or learn better study techniques and effective strategies for that? Do they know of outside resources? We are not all experts in everything. Do I know the outside resources that I can guide somebody towards and say, “You are struggling with this? Go watch this video and talk to this person. Let them help you.” I can’t do that but they can.
That’s all great advice. To wrap this episode up, let’s touch on two big things. A lot of people are always questioning how to decide what’s bad and good. Let’s talk about board passing rates and attrition rates. Let’s start with the board passing rate and the benchmark. I looked this up because I was like, “I want to know the benchmark.” It’s 80% for schools to keep their doors open but the national average is right around 84% passing rate on the NCE, which is our National Certification Exam.
When you look at benchmarking and current rates, that is a little bit of a variation. It can be a little bit confusing when you start looking at the way it’s worded, especially when we look at the NCE or National Certification Exam reports that have been released. What the Council on Accreditation does is look at programs and have them benchmarked. It is over a 1-year period and a 5-year period.
They monitor every year, look back over a five-year standard also, and try to say, “What are your board pass rates?” When they say board pass rates, they are looking at two factors. One, they will look at it the first time. In other words, it’s what they consider the first-time pass rate timeframe and then after that. The reason they do that is that we’ve got to have programs for graduating students to be effective practitioners, not so we are taking tuition dollars and putting them in the pockets of universities.
There has to be an accountability fact there in programs. I love that accountability fact. I try to focus on board pass rates for our program. I love that accountability fact because it makes me provide better education to the students, knowing that I’ve got to meet the standard and that if I don’t, the Council on Accreditation is going to either put us on probation or close our doors if we are not good enough at getting that board pass rate there.
That’s what the benchmark is. The national pass rate is about 84.6% in the 2021 report. We are still waiting for 2022 to come out. It won’t come out until the end because we have some programs that graduate in May that still do a December graduation. In the report for 2021, when we look at the 84.6%, the report was showing, that shows that we are getting more students to pass than not.
What’s scary to a certain degree is we do see some programs at 100%. That means there has to be some below 80% when you do the math on it because you can’t have people passing programs in the 90th percentile passing, and then everybody is above 80%. The math doesn’t work. We need to see what’s going on with these programs and fix that. Those are the ones you may want to look at and see what’s going on.
Just because they may have below the 84%, which is the national average that doesn’t mean they are bad programs. It means they may have had some things going on where a faculty had left, some problems with clinical training sides and academic people, or whatever it may be that contributed to that. You always want to dive in and not say, “They are less than the national average. I’m throwing them out the window. I won’t look at them.”
You want to see what they are doing differently. Have they identified the reason below that? Are they making a difference to try to improve that? I will give you an example of that. When I first started in education, we had within our program a dip in our board pass rates. We had been pretty high over the years, and we dropped to below the national average and below that benchmark one time.
Thank God they looked at it over a five-year timeframe because our five years were unbelievable. We had this one little blip on the radar. The first thing we did was to reach out to every single one of those who did not pass that year and tell them what was going on. We found out that there were a lot of extraneous factors such as cars, trips, boats, land, and parties.
It is not a theme that was just for our program. It happened at a lot of places but we found out that there were a lot of factors that allowed them to be able to focus on that instead of focusing on studying for the NCE because we had a timeframe in their last semester where we gave them a day in the week off to study for boards.
It was an unstructured day of the week studying. Therefore, a number of them didn’t because they felt comfortable where they were. They were doing all this other stuff, so they didn’t study well and pass the board. The very next semester or the next year, we designed an in-house board prep course. Our pass rates immediately went back up.
It’s not patting ourselves on the back but it’s talking about how a lot of programs have done that. Maybe it’s not the same exact thing we did but they have looked at why their pass rates were not high enough based on either the benchmark or the national average and made changes. You want to see the programs doing that.
You found out that you need the accountability piece at the end because we all have senioritis. The last point to wrap this up is let’s talk about attrition because sometimes this can look scary. Also, board passing rates can fluctuate from year to year. It makes you question, “If their attrition rate is 30%, what’s going on?” You don’t know what’s going on. Let’s talk a little bit about that.
[bctt tweet=”Attrition rates can tell you some things, but it’s not an end-all-be-all.” via=”no”]
Let’s talk about math because that’s all the attrition rates are. It is nothing but statistics and math. You know as well as I do statistics can be shown and viewed any way you want them to be viewed, positive or negative, depending on the scenario or who’s presenting the statistics. I always say that you should look at attrition rates. Attrition rates can tell you some things but it’s not an end-all-be-all.
When you look at attrition rates, and you see that percent, the very first thing you need to do is figure out how many students were in that course, program or cohort. Here’s the thing. If I’ve got a 30% attrition rate, let’s go with that, and you are at one of the programs that I know in the Midwest, they have ten students in their program. That’s three students.
If you are in the Southeast, where some of us have 30 and 35 students, you are talking about 9 to 10 students. That’s a big difference. If you have only three students drop out of a program that’s got 30 in them, you are now at a 10% attrition rate, which doesn’t look good. That’s why I say that you can’t go by just the percent. You need to look at the number because that’s going to make a difference.
If I told you 10%, you would go, “That’s a borderline number.” If I say there are three students out of our course, you are like, “I don’t want to be 1 of those 3.” If I tell you it’s one, then that aspect is like, “One is not bad.” I always go back and look at the main number. How many were in that overall cohort? Here’s the second thing to think about. Why do you have an attrition rate? Anesthesia is no different than any other profession.
You are pretty sure you know what you want to do and what you are getting into but you never know until you are in the middle of it and in the thrones of the operating rooms in a pediatric case, an open-heart case, or even a general case. You don’t know. Shadowing and observation are wonderful. They give you an idea of something that you want to move towards and can confirm, “This is a profession I’m pretty sure I want to go into,” but until you truly get your hands on it, you don’t know.
When we talk about attrition rates, it’s not all about the program. Some of it is this. If you are looking at 25%, 30%, and 35% attrition rates, look and see what’s going on with that program, especially if they are in the numbers of 30%, 35%, 40%, or 50% I’ve seen at some programs. If you are having fifteen people drop out of a program or not make it through, you might want to think about that and see what’s going on.
If you are in a program that has 35 students and you’ve got an attrition rate of 10%, you are talking about 3 or 3 and a half students. What is the difference? Why did they do it? I have seen this before. Academically, they don’t make it no matter how much help you give them. Clinically, they are wonderful practitioners. They can handle the CVICU, the neurotrauma, and the medical ICU.
They can handle that unit. They can go up against that physician and deal with the patient family that nobody likes. They can handle vasoactive drips, monitors, and vents. All of that works but when you get them in the academic setting and understand the academic material, they can’t pass. They struggle with that, whether it’s test anxiety, comprehension, retaining of the information or whatever it may be.
Did the program make any mistakes while 90% of their class graduated? That’s not necessarily on the program. That’s on the individual who could not adapt or make it through the program. I’ve seen this before. A 3.7, 4.0 student gets into a program. They continue to be 3.7, 4.0 through the program but once they get into the clinical setting and get enthralled in that and go, “This is not what I thought it was. I am out the door.” You are like, “You are a 4.0 student. You are doing well academically.”
They are like, “I can’t deal with this clinical side. This is not what I thought it was.” I tell people, “Try to find out.” That’s going to be a hard thing because not all programs are going to say, “Here’s what our attrition rate is for. Here’s what caused it.” You might have to do a little more digging in there. Attrition rates are good. That can give you an idea to compare some programs but comparing along with other factors because they vary so much.
There are some whose attrition rates are there because they admit a lot of people. They admit 51 and 35 to graduate. That extra fifteen helps them with some tuition dollars up front to pay some bills maybe or maybe not. Who knows? It has a lot of people associated with it and applicants that come in to get accepted that don’t make it through. You want to ask why.
That would be good too. I always tell people, “Look year after year because every now and then, you will see these programs that maybe one year they dipped in the attrition rate but then they went back to their baseline the next year.” I have people reach out to me who have been dismissed from programs. I wouldn’t say all the time but in my two and a half years of mentoring, I’ve had a decent handful of people who were like, “Jenny, I need help.”
The vast majority of the time, when students get dismissed from programs, 9 times out of 10, it seems to be because there’s something in their personal life that hindered their ability to perform academically but it usually stems from them not reaching out soon and often enough to get help, meaning they try to deal with whatever problem it is on their own and then they fail a course. It’s like, “Did you ask for help?” “No, because I thought it would be okay.”
Faculty members cannot help you if they do not know you are struggling. I want to make sure I hit home with that. You have to make sure that if you are struggling both personally, financially or anything, you have to make sure you let them know so they can try to help you and work with you as best as they are able to. They want to pass their students. They want you to all pass.
Most programs, and I say most because I don’t know all of the programs and their faculty from all 127 across the nation that I know, their anticipation is, “My goal is if I met 10, 30 or 40 individuals in my program, we want 40 to graduate, pass the boards their first attempt, and have a job post-graduation immediately, if not have the offer before graduation.” That is our goal.
Talking about wrapping up and looking at a summary of what we have been talking about, what we dove into is a ton of information on how you choose the program. What are the factors that you want to look at and consider for the program when you are looking to go to anesthesia school? It can be summed up in a very short sentence or phrase.
It varies from year to year. You need to stay on top of it. In other words, it’s not going to be the same all the time. These are the factors, and none of these are end-all-be-all factors by themselves. All of these need to be considered altogether. Make sure you are reaching out to the right people to get the information and help you make that all-important decision of which program you want to go to.
It’s a great way to summarize everything. The key is getting involved, going to open houses, coming to our conference, and touching base with current students and program faculty. Don’t just do it one time, as Richard spoke to. Make a plan from the time you choose to pursue CRNA that every year, you are actively touching base with these programs and going to conferences and open houses.
It’s not just one time for a check in the box because things change and faculty change. I love that advice. Richard, thank you so very much for joining us. I hope you enjoyed this episode as I did. It was enlightening. There’s a lot of gold. Hopefully, you download and save it for your CRNA school search. We will see you for the next episode.
Thank you, Jenny. I enjoyed it.
Thank you so much.
- Richard Wilson – LinkedIn
- Council on Accreditation
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