September 19, 2019 • 41 mins
The entire medical industry has seen significant controversy when it comes to recertification and certification and the CRNA world has been no different. This episode I talk to Dr Terry Wicks the incoming President of the National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA) about the new CPC program and recertification in general.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
INTRO (00:01):
Welcome to anesthesia deconstructed science politics
realities.
Listen, as medical professionalsjoin industry expert, Mike
MacKinnon to discuss the latestscience and medical
advancements, the effects of ourpolitical climate and the
realities of today's changinghealthcare environment.
Let's get started with yourhost, Mike MacKinnon.
Mike MacKinnon (00:27):
Hello everyone and welcome to the very first
episode of anesthesiadeconstructed science politics
and realities podcast.
My name is Michael MacKinnon.
I'm going to be your host.
I've been a CRNA for about 10years and I will be bringing you
through the process of all thestories and interviews over the
(00:47):
coming episodes.
On this episode, we're going tobe talking to Dr.
Terry Wicks, who is the incomingNBCRNA president about the
continuing professionalcertification program, otherwise
known as the CPC, which ishighly controversial.
Today's guest is going to be Dr.
Terry Wicks, who is the incomingpresident of the NBCRNA, which
(01:10):
of course is the recertificationbody that recertify CRNAs.
Dr Wicks began his career 20years ago where he graduated in
1986 from the U s armyanesthesia program with a
master's degree and he also wenton to receive his doctorate.
Just this last year andmaintains an active clinical
practice in North Carolina.
(01:30):
In addition to that, Dr Wickswas the American Association of
Nurse Anesthetists President in2006 2007 in his professional
life.
He's currently a professor inthe nurse anesthesia program at
the University of NorthCarolina, Greensboro and he is a
founding member of the rock bandvolatile agents, which is his
true passion he tells me, so sitdown, enjoy your ride in your
(01:55):
vehicle, listen to our podcast.
This is going to be aninteresting episode, important
for CRNAs.
Get the information.
Let's get it on.
Welcome Dr Terry Wicks for theshow and congratulations on your
doctorate!
Dr Terry Wicks (02:09):
Yeah, thank you very much.
It was hard work, but obviouslyI've been paying it off.
I got a job teaching at UNC gand so I'm where I want to be in
my career right now.
Mike MacKinnon (02:18):
Excellent.
That's all you can hope for.
So I mean, as you know, therollout of the NBCRNA CPC
program has been controversialsince its beginning in Boston
when it was originallyannounced.
There's a large group of membersthat are very concerned about
what's happening, what's goingto happen.
But I think in order tounderstand it best, we kind of
have to set the stage with thehistory of the NBCRNA and you
(02:39):
know, how it works, how itinteracts and functions with the
Coa, the AANA and members.
Cause I think people are prettyunclear as to the difference
between the NBCRNA, the AANA andthe coa.
Can you enlighten us to that alittle bit?
Dr Terry Wicks (02:51):
Absolutely.
And you know, I understand, uh,you know, where there's some
confusion because even 10 yearsago when I was on the board of
directors of the, and hey, Ilacked the kind of clarity that
I think is important for AANAmembers to have when they're
looking at these relativelycooperative, yet
administratively autonomously,these agencies that are separate
by financially and throughtheir, through leadership, we
(03:14):
have to turn the clock back.
We have to look all the way backto 1975 when the AANA members, I
had a business meeting approvedestablishment of the council to
oversee accreditation of theirprograms and certification
process for nurse anesthetist.
Both those entering theprofession and a in a couple of
years later for those who wouldbe recertified.
(03:35):
And so now that process is asmost seasoned sons CRNAs know is
well over 50 years old andhadn't really changed much since
its outset.
And then about 10 or 12 yearsago in the process of
renegotiating the relationshipsbetween AANA and the council on
certification andrecertification, uh, it became
obvious that the organizationshad wrote apart, at least in the
(03:58):
sense that their missions wereclearly separate day AANA
obviously being the politicaladvocacy organization and the
council on certification ofnursing really focusing its
attention on certifying newentrants to the profession and
the council and recertificationfor maintaining their credential
over time.
And a decision was made by thosetwo councils to form a
corporation, which they renamedthe NBCRNA, the national board
(04:22):
for certification andrecertification of nurse
anesthetist.
And that really was sort of thatlaser bright line that separated
those two functions ofcertification recertification
from the broader politicaladvocacy role of the Ana.
Now what they did very shortlyafter that starting I think in
about 2008 as they started tolook at their the
(04:42):
recertification process and thechanges that were taking place
in the recertificationcommunity, not just nursing but
organized medicine, we'rewrestling with trying to find a
way to update that with thecurrent recertification standard
and after doing a professionalpractice analysis where AANA
members determined those thingsthat were most important to know
(05:05):
in order to practice safelyirrespective of their practice
setting.
The CPC was conceived andcomposed of several parts.
The first part of course isfamiliar to most and that is
continuing education credits,but the added component was that
there was a going to be arequirement for those continuing
education credits to be assessedin order to be recognized, at
least for the classificationthat we call class a.
(05:27):
The CPC also contains anopportunity for CRNAs to be
recognized for doing a serviceto the health care industry and
to the organizations andeducating uh, ancillary and
allied health professionals andget credit for those educational
efforts as well as serving oncommittees and doing community
work.
Even even taking part in missionprojects.
(05:48):
And those are the class Bcredits and of course they don't
have to be prior approved andthere are very simple and in
terms of what they require interms of documentation.
The other two pieces that reallydo seem to cause a lot of
confusion are the modules and ofcourse the CPC assessment.
The modules originally weregoing to be required every four
years and they covered the areasof technology, pharmacology,
(06:11):
airway management and physiologyand pathophysiology.
And those four domains overlapwith those areas where CRNAs
identified being most importantfor safe practice.
The intent of the modules is tokeep CRNAs up to date with
emerging technology andinformation in the anesthesia
community.
And they derive their contentfrom anesthesia research that's
(06:34):
been published.
The vendors have the moduleshave the ability to provide
whatever baseline and backgroundinformation to support the new
information that they choose to,but the key is is that whenever
a module is approved orrecognized by the NBCRNA, there
are specific objectives thatthat vendor has to address in
their a module or provideinformation to support their
(06:56):
decision not to cover that.
The beauty of those modules asthey satisfy class A credit and
I think compared to what itcosts to get other classes
traveling to meetings and payingentry fees and staying in hotel
and restaurant class A creditson the modules are relatively
inexpensive and maybe a fewhundred dollars from the AANA to
get packages that provide youwith them.
(07:18):
We're about 17 or 19 class eightcredits, which is really a
bargain, but one of my heroescalled it the elephant in the
room of course is the CPCassessment and a course.
I think a lot of the anxietysurrounding that CPC assessment
is when it was originally rolledout, it was framed as a pass
fail test.
(07:39):
And of course me like everyoneelse that his concern would be,
you know, aware of the threatthat if you fail to be
successful on the examination asit was originally conceived, one
could possibly have in jeopardytheir ability to practice as the
CRNA and support their family.
Mike MacKinnon (07:57):
So with the exam and the modules that are being
done by some third party groups,I think some of the questions
are, you know, are these, arethese third party companies,
contributing revenue to theNBCRNA or are they doing it on
their own?
What is the process for thatthird party company in order to
be able to be allowed orcertified to, to provide these
(08:18):
modules?
Dr Terry Wicks (08:19):
That's a great question.
Originally we set specificobjectives for information
content that the module had tosatisfy in order to be
recognized by the NBC RNA.
The NBCRNA does charge a fee forreviewing the module to ensure
that the content is contemporaryand that it satisfies those
objectives.
(08:40):
But at that point, the NBC orRNA basically is taking a hands
off approving organizations likethe AANA.
We'll look at the module anddetermine how many continuing
education credits it will awardfor that module.
The vendor themselves set theprice for the module, and so the
NBCRNA gets no money from themarketing of the module.
(09:02):
There are state associationsthat have submitted modules for
recognition.
A, of course obviously does, andthere are private organizations,
healthcare providerorganizations which have created
modules for their employees.
So the revenue stream from themodules goes back to the vendor
and the NBCRNA never sees that.
And of course they don't haveany, a role that setting the
(09:23):
price for those.
Mike MacKinnon (09:24):
And so what is that initial fee for a vendor if
they choose to go down thatroute?
Dr Terry Wicks (09:30):
Well, that's a really great question, Mike.
You know, the initial last toreview a module for recognition
as$2,500 per module and thenthere's a$500 annual fee per
module to review that to ensurea currency of the module.
We are getting it at a point intime when a lot of those
original modules are going to beresubmitted for review, for
(09:50):
update and right now they arestill trying to determine at the
office with the most appropriatefee for that would be, and I
imagine it'll be closelyresemble what we've charged in
the past and of course we'rereally interested in, it's
covering our human resourcescosts and not really making a
profit on that.
Mike MacKinnon (10:06):
Is that a lifetime fee?
Basically you create a module,this is the cost and then from
there on in it's continues or isthere ultimately new fees to
maintain that?
Dr Terry Wicks (10:14):
I think that uh, the NBCRNA has required the
vendors update those modules ona periodic basis.
I think they have to bemodernized every four years and
they have to be resubmitted.
I don't know if there's adiscounted rate for resubmission
for our a renovated module or ifit's the same price, but it's
probably similar because thatwhole price point is set based
(10:36):
on the number of man hours andthe human resources required on
the part of the NBCRNA to reviewthe module.
Mike MacKinnon (10:42):
Right.
So basically you've covered whatthe CPC is and how it works.
I guess one of the questionsthat I hear a lot from members
is why did we need this change?
What was wrong with our originalprogram that it wasn't
sufficient enough to continue?
Because as you know, crns have along history and track record of
incredible safety.
And so if, if that was the case,why do we need this upgrade?
Dr Terry Wicks (11:03):
Yeah, well that's a great question Mike,
and I'll be honest with you, youare absolutely hit the nail on
the head.
There are very few healthcareprofessionals that have a track
record of safety and thatcompares to nurse anesthetist.
But what we do know is that inevery field of human endeavor,
uh, those people who areprobably in most need of
updating their practice orrenewing their skills, they're
(11:26):
probably least able toobjectively judge their own
skills.
And that's called the dunningKruger effect.
And it applies to lots ofdifferent domains, not just
health care but the use of humorwritings, sports, uh, ability to
tackle math problems.
So the interesting thing is, isthe least skilled are the most
likely to overestimate theirabilities, whereas the most
skilled people tend tounderestimate their abilities.
(11:48):
But that's really an aside.
You know, the driver was reallythose which credential the
NBCRNA to certify certain nurseanesthetist.
And that includes the NationalCouncil on certifying agencies
and the accrediting board perspecially nursing accreditation.
And those boards require acouple of things that are
(12:10):
important.
They require that ourrecertification model should
include a multimodal approachthat encourages individuals to
continue activities essentiallyto maintenance of knowledge and,
and continuing practice oftheir, their specialty also
stipulates that recertificationshould be time limited and
should last for no more thanfive years.
And then the final piece ofthat, which caused a lot of
(12:31):
consternation, is that thequestion was asked, well, you
know, I've been practicing for25 or 30 years, why should I be
grandfathered?
And the black and white print isbasically says that
grandfathering may have beenused before to satisfy initial
certification, but they insistedthat no longer be the case.
So our accrediting bodiesrequired for us to remain to be
(12:53):
a certifying agency that we makethose kinds of changes.
Mike MacKinnon (12:56):
Right?
So when it comes to that change,I think a lot of people look at
it and say, well look, if thischange doesn't predict clinical
competence, you know, you're notin any way, particularly testing
a crns ability to provideanesthesia safely, but simply
asking questions or reviewingmodules and then having a test.
So how would you respond tothose concerns that if it's not
(13:16):
going to predict clinicalconfidence, it's not doing
anything extra, what is thereason then that's what a lot of
people I think are asking.
Dr Terry Wicks (13:23):
Well, that's a really good question.
Of course, you and I both knowthat clinical competence really
encompasses a number of domains.
It's not only knowledge but it'salso judgment and decision
making.
And in addition to that,obviously you gotta dovetail
into that, you know, psychomotorskills, uh, and work ethic and
you know, ethical issues towardspractice.
What the NBC RNA recognizes isthat we can assess knowledge.
(13:47):
We're relatively easily, we knowthat that's a time proven
scientific fact and we can alsodovetail into that a degree of
evaluation of decision making.
But at that point then we wereentering into a real gray area
after that.
So what the NBC RNA is engagedin is, uh, several processes
which will change the NBCRNA andthe CPC over time.
(14:09):
Uh, we have a committee rightnow investigating ways in which
we can dovetail emulation intothe CPC.
And they are looking at thewhole spectrum of stimulation
from high fidelity patientsimulation to virtual reality.
And there's some evidence thatvirtual reality can be
beneficial in terms ofevaluating skills and decision
(14:30):
making.
And we are also have a committeethat's investigating the
experiences of othercertification bodies.
And new technologies for thedelivery of longitudinal
learning, which is very similarto the ASA Moca or the Moca two
that ASA members engaged in.
And there's some good evidencethat's accumulating when people
participate in Longitudinalalerting platforms, their
(14:51):
knowledge actually does increaseand that they perform better
over time.
So those are a couple of thingsthat the NBCRNA has got on the
front burner.
Uh, we're excited about them andwe're really looking forward to
seeing the results of thosecommittees work probably
delivered to our board withinthe next one to two years.
And those things will influencethe pathway that the NBCRNA
already takes in its researchvacation growth.
Mike MacKinnon (15:12):
All right, so this is an evolutionary process
and at some point in time downthe line with the expansion of
virtual reality and onlinesimulation, there will be some
direct clinical testing.
The way people think of clinicalcompetence isn't of course
knowledge base.
As you know, they think of it aswell, I do anesthesia every day
and my patients wake up and dogreat and no one complains.
So that's my clinicalcompetence.
(15:34):
At some point there'll be afunction of testing that down
the road with possible virtualreality or simulation.
Dr Terry Wicks (15:40):
Yeah, and it may be something that we offer as an
option.
Is this to substitute part ofthe CPC or it may be dovetailed
in CPC and total, it's hard totell at this point in time, but
I do want to emphasize, and Ithink sometimes gets lost that
even from the beginning, peoplelike Dr Chuck Bociano who was
one of the first presidents ofthe NBCRNA after the CPC was
(16:00):
launched and he wouldn't, whowas a past president of NBCRNA
and most recently Dr Bob Hawkinsall have said repeatedly that if
the CPC looks the same in 10years as it does today, then we
will have failed.
So we are continually looking atways to improve the platform to
make it better, to make it morerelevant, to reduce the burden
(16:22):
that it imposes on practicingCRNAs and to make it an avenue
for improving practice.
And one of the things that we'vegot on the, on the front burner
right now is we've engaged witha researcher to look at the long
term outcome changes that may berelated to participation in the
CPC by looking at historicaldata and then data moving
(16:43):
forward from 2016 when the CPCwas launched.
And so we're going to be able towin over time.
We're going to have anopportunity to look at those
data and see involvement in theCPC does make a difference in
patient outcomes, which isreally our first primary focus.
Mike MacKinnon (16:57):
Right.
I think, I think that alleviatessome of the concerns people have
in that there's, you know,there's an environment right now
where medicine and otherprofessions are looking at their
recertification process andeliminating some of these
components in favor of otheroptions or in some cases,
removal altogether.
And I think that, you know, whenpeople see that from our
profession, they look at it andsay, well, why?
(17:18):
Why do we have to do it ifthey're not doing it?
And so you know when you discussthe evidence, well, okay,
there's evidence.
They're suggesting that this hasthe potential to increase
knowledge over time.
And I think it's great that youguys are going to do some
research to show that over time.
How do you respond to thosepeople who say, well, if
medicine's not doing it, ourprimary competitor physician
anesthesiologists are, havemoved to Moca and have
(17:40):
eliminated their simulationexams, all that kind of stuff.
Why do we need to do it?
What separates us?
Dr Terry Wicks (17:46):
Well, I think one of the things that gets
overlooked is that by changingthe CPC from a pass fail exam to
changing their to basically anassessment with a performance
standard, we are really givingnurse anesthetist to take the
CPC and opportunity to get asnapshot of where their
knowledge deficits may lie.
And I can tell you from personalexperience, when I came to the
(18:08):
university and started doingdidactic teaching, things had
changed tremendously in the 25years since I graduated from
Madison.
You just go on.
And I've been giving continuingeducation lectures for my entire
career.
And you know, I think somepeople would argue maybe that
I'm kind of person that keepsup, but I was done how much I
had to learn myself in order toteach entry level crns.
(18:30):
So, you know, I think it's easyto lose track when you're
practicing every day at how muchthings do change.
And I think one obvious areawhere that is the movement
towards a limited or zero opioidadministration during January as
the easier early recovery fromanesthesia and surgery that's
new on the horizon.
Uh, I think there's a lot ofpractitioners that are still
(18:50):
finding out about, you know,drugs like Precedex and the role
of non-steroidals and reducingpain experiences
postoperatively, explosiveinterest in the use of ketamine
for depression, uh, and forchronic pain and PTSD.
So, you know, what we're hopingto do is give people a snapshot
of, Hey, here's the place whereI could probably improve my
practice and let them then gettargeted education to address
(19:14):
those shortcomings and theirknowledge.
So that's one value that wouldbe missing if we just eliminated
the CPC assessment altogether.
Mike MacKinnon (19:21):
Absolutely.
One of the concerns with theexam, going back to the exam
itself is although I think itwas an amazing move for the
NBCRNA to eliminate this wholepass fail, you know, cause there
was so many concerns aboutpeople's jobs and what would
happen to their certification intheir state.
But one of the things thatpeople are still concerned about
is the whole idea that, well,what if I pay, what if I fail my
first attempt around at thisexam?
(19:42):
So although it's not pass fail,there's going to be a number of
things that I maybe didn't dowell on and maybe it's a lot of
them.
If that happens, is thisinformation discoverable by
their employees or employers?
Can they, can they look in thewebsite and see, oh, you know,
Mike failed four modules and hehas to go back and do all this.
Is that something that theycould find out?
And I only mentioned thatbecause it could be a real
(20:02):
concern for people, you know, ifthey're working somewhere that
that could be found out and thenpossibly them in some way be
impacted by it.
Dr Terry Wicks (20:10):
Yeah.
And I think, I think that's alegitimate concern not only
from, for example, a privilegingand organizational level, which
obviously would be a concern oreven if that information were
disclosed at trial, uh, in anevaluation of someone's standard
of care.
And so the posture of the NBCRNA historically has been not to
release those results.
(20:31):
Certainly would not be availableto the public on NBC or any
website.
And I think it would probablytake a court ordered subpoena to
get those results that has notbeen tested in the past.
I know for the NCE exam, wedon't release those results
immediately to the takers of thetests themselves.
We do release them to theprogram directors after a
certain period of time.
(20:51):
And if the program directorwants to share those with the
students, they have thatopportunity.
But we take very seriously ourobligation to protect that kind
of information.
And as I said today, that hasnever been tested.
But our posture right now is notto in any way, shape or form
disclose that kind of privateinformation.
Mike MacKinnon (21:11):
Yeah, that makes sense.
It certainly is something thatI, I've been hearing a lot of
people course of really happythat it's no longer pass fail,
but very concerned about howthat could impact them later.
So as it, as the whole at CPC,uh, relates to the NBCRNA and
the increased costs for crnsover time for the MPC RNA CPC
(21:31):
exam and the modules, a lot ofpeople look at it and have the
criticism that, oh, you know,the NBC RNA is doing this just
to make more money to put moremoney in the coffers.
Uh, it's a new way to expand how, revenue stream with online
simulation all these things hadpossibly coming and of course,
the exam.
And how would the NBCRNA respondto that though?
(21:52):
That criticism,
Dr Terry Wicks (21:53):
you know, I think it's is a reasonable thing
for people to ask that questionbecause you know this is you
know the money that they have toinvest to sustain their working
career and I think it's areasonable thing for people to
take a hard look at that and askthe question.
Both I and John Preston who isone of our chief credentialing
officers take a close look atthis last year and based on our
(22:15):
estimation of what it cost inthe past to maintain
certification, including theactual cost that it's given to
the NBCRNA, the$55 or so or ayear, the cost of continuing
education and comparing all ofthose things across the board,
we believe that participation inthe CPC is going to be very
similar to what it costpreviously to maintain your
(22:38):
certification.
Particularly, you know, therewas a hard question asked about
what we were going to charge forthe CPC assessment itself.
And I, I read a comment onsocial media made by someone
that we could not possibly bringthis online for less than a
thousand dollars a charge perperson.
But, um, our finance departmenttook a hard look at the cost of
(22:59):
creating, maintaining andupdating the CPC assessment and
what it costs the NBCRNA toevaluate these other programs
that we've talked about,simulation, longitudinal
learning.
And we felt like we could bringthat to the market for$295 cover
our costs and have enough extrarevenue to sustain these other
programs that we'reinvestigating.
(23:20):
And so we're really happy thatwe got it down there because for
10 years we've been saying, hey,we think we can bring this test
forward for$300.
And so actually we gotunderneath that a little bit.
And the other thing is, is aswe've talked about in the past,
Mike, is that, you know, ourfinancial reserves are pretty
healthy and people look at thatand are critical of it.
But probably like most peoplewhose investment accounts have
(23:41):
done very well over the past 10years because of the growth in
the stock market and a good bitof our financial reserves are
also a direct result of our wiseinvestment policy and the good
fiduciary responsibility of ourboard of directors.
We use those resources to fundprojects like we've just talked
about the the simulationinvestigation and Longitudinal
(24:02):
assessment and also to provideprograms that generally don't
generate revenue streams for us,like the nonsurgical pain
management certification, whichis something that has cost the
NBCRNA at a loss throughout hislifetime.
And if we have the opportunity,the demand is there to provide
other certifications, whether itbe for regional anesthesia or
obstetrics or whateverpediatrics, whatever that market
(24:24):
asks for, we will look atkeeping the cost of those
programs if they are created atan absolute minimum and the way
that we can do that because wehave healthy financial reserves.
Mike MacKinnon (24:34):
Dovetailing back to the history, there's some
discussion I know about members,they seem to have some confusion
about the AANA, the NBCRNAconnectivity and how they're
related.
And I know originally the NBCRNAwas just part of the AANA and
was not autonomous, butsomething occurred at one point
in time in the history of theAna that resulted in the NBCRNA
being required to be autonomous.
(24:55):
What happened there?
Dr Terry Wicks (24:56):
Well, there's a couple of things.
I think that the Department ofEducation and the national
credentialing bodies recognizethat there has to be a laser
bright line between the folksthat are doing accreditation of
educational programs.
Those folks that are doingcertification and
recertification and the folksthat are providing advocacy for
the profession, so they have tobe separate.
(25:16):
In fact, the MDAs long time agowanted to take over education of
crns and that was one of thethings that prompted the
independent and autonomouscreation council on
accreditation to show that therewas that laser bright line and
also similar rationale was forproviding the autonomy and
independence of the NBCRNA or asit was known at that time, the
(25:37):
two separate councils.
And that's been very importantfor the profession because that
allows us to stand up and say,you know, no matter what our
advocate might say in Washingtonor at state legislatures or at
the boards of health or medicineor nursing, our credential is
defensible because it'sindependent.
It has a separate board ofdirectors that all I have is a
primary mission protection ofthe public through creating
(26:00):
credentialing processes thatpromote lifelong learning and a,
that is rock solid.
And that not only protects ourpatient, but it protects the
integrity and the longtermviability of the profession as
well.
Mike MacKinnon (26:13):
Yeah, I remember having those discussions with
you in the past.
Now, the one thing that, aboutthe NBCRNA is, is it's the only,
recredentialing agency forCRNAs.
And I think generally peoplefeel competition is good and
there's a discussion amongmembers that i t kind of ebbs
and wanes about, well, why don'twe have another body?
And if we did have another body,how would that look?
(26:35):
What are your thoughts on theidea of a, of a n additional
credentialing body to competewith t he N BCRNA?
Dr Terry Wicks (26:41):
Well, I think, um, I think that's an
interesting conversation to havebecause you know, the reality is
, uh, our credentialing body,the NBCRNA is a pretty complex
organization in terms of it's aresearch arm back to that.
It provides a certificationexamination for new graduates.
And in all the things that we'vetalked about with regards to the
CPC, no, as far as, you know, myperspective, and I think, you
(27:04):
know, the perspective of theNBCRNA is, you know, if somebody
else wants to create another, uh, certification organization or
recertification organization,you know, they're at liberty to
do that.
It'll still be a costlyundertaking, especially if you
want to recreate, at least inprinciple, a lot of the services
that the NBCRNA provides.
So if someone has the, you know,has the resources and the
(27:25):
motivation to do that, they arecertainly at liberty.
The one insight that I wouldoffer though is that a new
recertification body were formedand it provided a certification
process that was less stringentthan what is provided by the
NBCRNA.
You know, I have questions aboutwhether state legislatures and
boards of nursing andprivileging bodies at a local
level would recognize that.
(27:46):
And of course the other side ofthat coin is if a renewed, a new
certification body came intobeing that was more stringent
than the NBC RNA, you know, howmany crns would, uh, would sign
up for that.
So, you know, as I said, I didthis tire right ribbon around
it.
You know, the NBC alreadyrecognizes that anyone can do
that if they want to spend themoney and create the platform
(28:07):
and the framework and, and getthat thing recognized nationally
through all the accreditingbodies and have at it.
Mike MacKinnon (28:14):
And so when, when it comes to things like,
uh, for instance, the CPC exam,the modules, if a new
credentialing body came about,would they be able to do things
differently?
So what I'm saying is, is therecould be the same level of
standard, but maybe they didn'thave an exam in the way that the
NBCRNA currently envisions it.
Or they did the modules in adifferent way or they had a
(28:35):
separate sort of setup butconsidered maybe equally
stringent.
Can they do that?
Is that acceptable?
Dr Terry Wicks (28:41):
Oh sure they can do that.
They just have to get on thetrack and run through all the,
all the barriers and get itcreated
Mike MacKinnon (28:48):
and so, and the other side is I know that the
NBCRNA and the AANA have arecognition agreement.
And so how does that recognitionagreement impact a new
credentialing body?
Let's say the AANP wasapproached and they said, sure,
we'll take it over.
How does that impact therelationship with the AANA and
NBCRNA?
Dr Terry Wicks (29:06):
Well, I think the AANA NBCRNA have done a
really a lot of very productivework over the past seven or
eight years to create acollegial relationship that
recognizes their separatemission towards the public and
towards the CRNA practice.
We feel as a board that we're ata point now where we really have
a good dialogue that goes onconstantly with the AANA board
(29:29):
of directors.
Our presidents talk regularly.
We have liaison between the twoboards that attend their
individual board meetings andthey have a frequent conference
calls.
If we have something that's onthe front burner that we think
the AANA board would like toknow about before, you know, it
goes public, we make an effortto get that out to them.
So if another credentialing bodywould come along, uh, you know,
(29:50):
they would have to go through asimilar process to develop a
relationship with any board ofdirectors and that would be a
challenge for them.
But you know that that's apossibility.
Mike MacKinnon (29:58):
And specifically that recognition agreement
recognizes the NBCRNA is theonly one by the AANA currently
until, until the 10 year renewalpoint.
Right?
Is that correct?
Dr Terry Wicks (30:08):
I believe that is correct.
Yeah.
Mike MacKinnon (30:10):
dovetailing onto the simulation, we talked about
that a little bit already.
You know, I think everyonecompares anesthesia to the
airline industry.
We talk about it all the time.
There's lots of comparisons evenwithin our textbooks.
And the airline industry has ofcourse done a fantastic job of
simulation training andrecurrent simulation training
all the time.
And there is a group of CRNAsthat say, well, you know, why
(30:32):
have an exam?
Let's just have a simulationexam, which really does test
everything that's going on, atleast the snapshots of the
biggest things.
What are the barriers tocreating that sort of a
simulation exam set up today?
Dr Terry Wicks (30:45):
Well, probably the number one is price.
It's an expensive undertaking toadminister rigorous stimulation.
Even if we just looked atcritical incident management in
the operating room, that mightbe a one or a two day process.
And so you can imagine running a54,000 CRNAs through that over
the course of a couple of years.
It would be pretty daunting.
(31:06):
The other piece of that istravel.
And you know, for our folks thatlive out in the west of the
Mississippi, uh, independentpracticing CRNAs, practicing
critical access hospitals, folksthat practice in, in areas of
the country where a simulationcenter might be day's drive
away, there's a potential forlost income, not only lost
income, but the cost of havingsomebody come in and cover for
(31:28):
them while they're gone.
And the other thing is thatthere's the specter of what if
you go to the Sim Center and youdon't do well, what do we do
with you then do we just say,well you can't practice until
you come back and do that again.
So there are lots of financialand logistical and practice
issues that really have to beresolved before, you know, we
would engage in a system ofsystematic high fidelity patient
(31:49):
simulation as a criteria forcore recertification.
So that technology is young andthings are changing constantly.
So there may be an opportunityto do virtual reality at some
point a remotely they could helpsatisfy that.
But to the analogy with theairline industry, there is no
doubt whatsoever that highfidelity simulation in the
(32:09):
airline industry has contributeddramatically to traveler's
safety.
And I would be pretty reluctantto get in an airplane where the,
where the pilot or copilothadn't undergone that kind of
rigorous critical eventtraining.
So that's something we've got tolook at in the long run.
You know, there are now prettyconvincing of published evidence
(32:30):
to support using a cognitive aidin the operating room to help
manage crises.
So that's another avenue that wewant to take a look at, line
down the road if, if that has aplace in credentialing or with
simulation.
So it's a wide open landscape.
So you know, we've got some workto do to see if there's a place
for that.
Mike MacKinnon (32:46):
Oh, excellent answer.
The NBCRNA, hasn't really said awhole lot about types of
practice models or anything likethat or how they feel about
them.
And as we know, CRNAs workingprobably three main practice
models, one in an anesthesiacare team with physician
anesthesiologists, often in amedical direction model, one to
four style or you know,collaborative practice where
(33:07):
everyone's in their own room orthere may be just one physician
for 20, 30, CRNAs.
And then of course anindependent practice style where
they're working to full scope ofpractice and, managing the cases
day to day and doing everyportion of that pre anesthetic
to post anesthetic process.
One of the questions is how hasthe NBRNA supported that full
scope of practice?
(33:28):
Kind of, you know, the CRNAs whoare all by themselves or with a
CRNA group doing this entirerange of things.
In terms of recertification,what things have, has the NBCRNA
already done or what plans maythere be to expand that sort of
offering to that group ofpeople?
Dr Terry Wicks (33:44):
Well I think that probably the most prominent
piece of evidence to show thatsupport was the creation of the
nonsurgical pain managementcertification course.
That's a pretty complex in ahigh level area of practice, but
it's one where particularlyCRNAs in the rural area
absolutely needed their support.
You know, the NBCRNA tries toprovide good information to the
(34:04):
council on accreditation and tothe AANA where appropriate to
help them in their advocacyefforts.
The NBCRNA specifically kind oftakes a, you know, an arms
length distance from a lot ofthe political charged
discussions that take place asfar as how CRNAs are able to
practice or in what areas you'reable to practice.
Now our main focus is makingsure that CRNAs keep their
(34:26):
knowledge up to date and thatour certification process really
meets the highest standards ofthe contemporary recertification
industry.
It's always going to be achallenge to remain apolitical
for the NBCRNA, but you'llalways be that resource for the
or for the AANA, to provide theinformation that we can to
(34:49):
support the CRNA practice.
Mike MacKinnon (34:51):
Well part of the reason I ask is because you
know, the NBCRNA has thismission to promote patient
safety and I, you know, as weare well aware, based on the
evidence, all available evidenceis CRNAs are safe in any model.
It doesn't matter what model youwork in.
And with this a continuous andconstant rapidly expanding full
scope of CRNA practice costsacross the country, both in
(35:12):
autonomous style models andindependent models and
anesthesia care team, sort of onthe wane, what actions has or
does the NBCRNA plan toundertake to help support that
model?
Because obviously, you know, ifthere's more and more CRNAs in
that kind of a model, there's anexpansion of the needs of those
CRNAs both in recertificationand certification and an
education.
(35:32):
And so with your certificationportion, how would you do that
best?
Dr Terry Wicks (35:35):
Well, I think we've been asked by a couple of
different interested CRNAs toevaluate the possibility of
providing a, perhaps inobstetrics certification
credential or a regionalanesthesia recognition.
So we have to look at thosethings very carefully,
recognizing that the possibilityexists that by creating that
sort of a recognition that it'spossible we could even box CRNAs
(35:59):
out from those areas ofpractice.
So that's something that we haveto look at very, very carefully.
But other than that, you know,we really have stayed pretty
well clear of the, of thepolitical discord out there in
the healthcare industry andreally tried to sustain our
focus right on there oncertification recertification.
Mike MacKinnon (36:15):
So at this point there's nothing, there's nothing
particularly specific at theNBCRNA does to support that full
scope of practice other than therecertification is broad.
Dr Terry Wicks (36:24):
Right?
It's really kind of outside ofour wheel house.
Mike MacKinnon (36:27):
Okay.
And then probably one of themost controversial things that's
happened in our professionrecently is the AANAs acceptance
of the, of this new title, anurse anesthesiologist.
And so that's givencontroversial both in a
political way, even internally,uh, and outside externally.
What is the NBCRNAs position onthat and how or what would the
(36:48):
NBCRNA be able to do to supportthat moving forward as it grows
in popularity?
Assuming it does.
Dr Terry Wicks (36:54):
So what we would have to do, uh, is to really
engaged in a, a, in a knowledgebased discussion what the NBCRNA
wants to do.
We have not undertaken thatformal discussion at a board
level.
And so the headline is that wehaven't considered that,
however, w e're not ignorant ofwhat's going on i n, in the
anesthesia community.
(37:15):
And you know, recognize thatAANA board of directors has
allowed CRNA's where permissibleto use t he descriptor, a nurse
anesthesiologist.
And I know that some boards ofnursing have recognized that.
S o I think what we're waitingfor before we really engage in a
discussion about that on apolicy level or as a posture is
to wait until we see where thetide is taking us.
(37:38):
U h, I know that there was abylaws change proposal that was
initially intended to be broughtforward t oday i n a business
meeting that was initially goingto ask for a change in the name
of the organization.
And there seemed to be a lot ofdivision about that.
And so that was withdrawn.
So we are really taking a couplesteps back.
We're g oing t o kind of watchwhere that goes.
Obviously i f that gained somemomentum, we're going to have to
(38:01):
look at what boards of nursingare designing, what state
legislators are deciding, u h,in terms of recognition of that
title.
A nd we'll kind of go fromthere.
Mike MacKinnon (38:09):
And so what, what would that look like?
Does it change therecertification exam title?
Does it change the process bythe, the certification is there
now two certifications, CRNAanesthetist, CRNA
anesthesiologist, you know,looking down the road in the
future.
If this got very popular and youguys decided that as an NBCRNA
you had to expand this offeringor do this and re-certification,
(38:31):
what, what does that look like?
Are there two different titles?
Is there one combined?
Dr Terry Wicks (38:36):
Well I think what we would have to do is go
back to our accrediting body,the National Council on
certifying agencies and theaccreditation board for nursing
specialty accreditation and havea conversation with them and
possibly even go as far up theline as the institute for
credentialing excellence and seewhat stipulations that would
have to be satisfied if we were,if we embarked on a change.
(38:58):
My guess is is that at leastinitially, and this is just
speculation, that there might bea period of time when when both
are recognized, but again thatI'm guessing is a little ways
down the line and obviously wewould have to have an intense
and a deep dive conversation ata board level about the
direction we want it to go.
Mike MacKinnon (39:16):
Excellent.
And so we basically come to theend of the interview.
Terry, I appreciate you beinghere.
It has been great.
A great conversation.
As usual.
What last things would you leaveour audience with about the
NBCRNA, the CPC and anythingthat they should know?
Dr Terry Wicks (39:33):
Sure.
I think that's a great question,Mike.
Thank you for asking that.
Uh, every time I have anopportunity to engage with CRNAs
on social media or face to faceat meetings or even in
individual institution where Ihappen to have a chance to visit
with CRNAs, I asked them to goto the NBCRNA website.
There is just an enormous wealthof resources there.
(39:55):
There's guidance, there's anavenue there to look at your
progress towards recertificationand get a graphic representation
of what you need to do.
Call the office.
Uh, our staff is availableseven, well not seven days a
week.
available five days a week.
They always answer the phone andif they don't have an answer for
you, they'll get one.
Reach out to us.
We are, we are at statemeetings, we're at private CE
(40:17):
vendors meetings trying to makeour presence and you know, ask
us questions, go to the website,get some additional information.
And, uh, we really hope thatpeople recognize that we're
working on their behalf as wellas on the behalf of the patient.
Mike MacKinnon (40:30):
Well, thank you so much, Dr Wicks.
I appreciate your time and havea great day.
Dr Terry Wicks (40:35):
Okay, thank you Dr MacKinnon.
I appreciate it.
OUTRO (40:38):
That's all for this episode of anesthesia
deconstructed.
For more information based ontoday's discussion, be sure to
visit us@anesthesia-deconstructed.com
you'll also gain access to ourblogs, editorials, and more
resources to keep you updated onthe science, politics, and
realities of today's medicalindustry.
That'sanesthesia-deconstructed.com.
Welcome to anesthesia deconstructed science politics
realities.
Listen, as medical professionalsjoin industry expert, Mike
MacKinnon to discuss the latestscience and medical
advancements, the effects of ourpolitical climate and the
realities of today's changinghealthcare environment.
Let's get started with yourhost, Mike MacKinnon.
Mike MacKinnon (00:27):
Hello everyone and welcome to the very first
episode of anesthesiadeconstructed science politics
and realities podcast.
My name is Michael MacKinnon.
I'm going to be your host.
I've been a CRNA for about 10years and I will be bringing you
through the process of all thestories and interviews over the
(00:47):
coming episodes.
On this episode, we're going tobe talking to Dr.
Terry Wicks, who is the incomingNBCRNA president about the
continuing professionalcertification program, otherwise
known as the CPC, which ishighly controversial.
Today's guest is going to be Dr.
Terry Wicks, who is the incomingpresident of the NBCRNA, which
(01:10):
of course is the recertificationbody that recertify CRNAs.
Dr Wicks began his career 20years ago where he graduated in
1986 from the U s armyanesthesia program with a
master's degree and he also wenton to receive his doctorate.
Just this last year andmaintains an active clinical
practice in North Carolina.
(01:30):
In addition to that, Dr Wickswas the American Association of
Nurse Anesthetists President in2006 2007 in his professional
life.
He's currently a professor inthe nurse anesthesia program at
the University of NorthCarolina, Greensboro and he is a
founding member of the rock bandvolatile agents, which is his
true passion he tells me, so sitdown, enjoy your ride in your
(01:55):
vehicle, listen to our podcast.
This is going to be aninteresting episode, important
for CRNAs.
Get the information.
Let's get it on.
Welcome Dr Terry Wicks for theshow and congratulations on your
doctorate!
Dr Terry Wicks (02:09):
Yeah, thank you very much.
It was hard work, but obviouslyI've been paying it off.
I got a job teaching at UNC gand so I'm where I want to be in
my career right now.
Mike MacKinnon (02:18):
Excellent.
That's all you can hope for.
So I mean, as you know, therollout of the NBCRNA CPC
program has been controversialsince its beginning in Boston
when it was originallyannounced.
There's a large group of membersthat are very concerned about
what's happening, what's goingto happen.
But I think in order tounderstand it best, we kind of
have to set the stage with thehistory of the NBCRNA and you
(02:39):
know, how it works, how itinteracts and functions with the
Coa, the AANA and members.
Cause I think people are prettyunclear as to the difference
between the NBCRNA, the AANA andthe coa.
Can you enlighten us to that alittle bit?
Dr Terry Wicks (02:51):
Absolutely.
And you know, I understand, uh,you know, where there's some
confusion because even 10 yearsago when I was on the board of
directors of the, and hey, Ilacked the kind of clarity that
I think is important for AANAmembers to have when they're
looking at these relativelycooperative, yet
administratively autonomously,these agencies that are separate
by financially and throughtheir, through leadership, we
(03:14):
have to turn the clock back.
We have to look all the way backto 1975 when the AANA members, I
had a business meeting approvedestablishment of the council to
oversee accreditation of theirprograms and certification
process for nurse anesthetist.
Both those entering theprofession and a in a couple of
years later for those who wouldbe recertified.
(03:35):
And so now that process is asmost seasoned sons CRNAs know is
well over 50 years old andhadn't really changed much since
its outset.
And then about 10 or 12 yearsago in the process of
renegotiating the relationshipsbetween AANA and the council on
certification andrecertification, uh, it became
obvious that the organizationshad wrote apart, at least in the
(03:58):
sense that their missions wereclearly separate day AANA
obviously being the politicaladvocacy organization and the
council on certification ofnursing really focusing its
attention on certifying newentrants to the profession and
the council and recertificationfor maintaining their credential
over time.
And a decision was made by thosetwo councils to form a
corporation, which they renamedthe NBCRNA, the national board
(04:22):
for certification andrecertification of nurse
anesthetist.
And that really was sort of thatlaser bright line that separated
those two functions ofcertification recertification
from the broader politicaladvocacy role of the Ana.
Now what they did very shortlyafter that starting I think in
about 2008 as they started tolook at their the
(04:42):
recertification process and thechanges that were taking place
in the recertificationcommunity, not just nursing but
organized medicine, we'rewrestling with trying to find a
way to update that with thecurrent recertification standard
and after doing a professionalpractice analysis where AANA
members determined those thingsthat were most important to know
(05:05):
in order to practice safelyirrespective of their practice
setting.
The CPC was conceived andcomposed of several parts.
The first part of course isfamiliar to most and that is
continuing education credits,but the added component was that
there was a going to be arequirement for those continuing
education credits to be assessedin order to be recognized, at
least for the classificationthat we call class a.
(05:27):
The CPC also contains anopportunity for CRNAs to be
recognized for doing a serviceto the health care industry and
to the organizations andeducating uh, ancillary and
allied health professionals andget credit for those educational
efforts as well as serving oncommittees and doing community
work.
Even even taking part in missionprojects.
(05:48):
And those are the class Bcredits and of course they don't
have to be prior approved andthere are very simple and in
terms of what they require interms of documentation.
The other two pieces that reallydo seem to cause a lot of
confusion are the modules and ofcourse the CPC assessment.
The modules originally weregoing to be required every four
years and they covered the areasof technology, pharmacology,
(06:11):
airway management and physiologyand pathophysiology.
And those four domains overlapwith those areas where CRNAs
identified being most importantfor safe practice.
The intent of the modules is tokeep CRNAs up to date with
emerging technology andinformation in the anesthesia
community.
And they derive their contentfrom anesthesia research that's
(06:34):
been published.
The vendors have the moduleshave the ability to provide
whatever baseline and backgroundinformation to support the new
information that they choose to,but the key is is that whenever
a module is approved orrecognized by the NBCRNA, there
are specific objectives thatthat vendor has to address in
their a module or provideinformation to support their
(06:56):
decision not to cover that.
The beauty of those modules asthey satisfy class A credit and
I think compared to what itcosts to get other classes
traveling to meetings and payingentry fees and staying in hotel
and restaurant class A creditson the modules are relatively
inexpensive and maybe a fewhundred dollars from the AANA to
get packages that provide youwith them.
(07:18):
We're about 17 or 19 class eightcredits, which is really a
bargain, but one of my heroescalled it the elephant in the
room of course is the CPCassessment and a course.
I think a lot of the anxietysurrounding that CPC assessment
is when it was originally rolledout, it was framed as a pass
fail test.
(07:39):
And of course me like everyoneelse that his concern would be,
you know, aware of the threatthat if you fail to be
successful on the examination asit was originally conceived, one
could possibly have in jeopardytheir ability to practice as the
CRNA and support their family.
Mike MacKinnon (07:57):
So with the exam and the modules that are being
done by some third party groups,I think some of the questions
are, you know, are these, arethese third party companies,
contributing revenue to theNBCRNA or are they doing it on
their own?
What is the process for thatthird party company in order to
be able to be allowed orcertified to, to provide these
(08:18):
modules?
Dr Terry Wicks (08:19):
That's a great question.
Originally we set specificobjectives for information
content that the module had tosatisfy in order to be
recognized by the NBC RNA.
The NBCRNA does charge a fee forreviewing the module to ensure
that the content is contemporaryand that it satisfies those
objectives.
(08:40):
But at that point, the NBC orRNA basically is taking a hands
off approving organizations likethe AANA.
We'll look at the module anddetermine how many continuing
education credits it will awardfor that module.
The vendor themselves set theprice for the module, and so the
NBCRNA gets no money from themarketing of the module.
(09:02):
There are state associationsthat have submitted modules for
recognition.
A, of course obviously does, andthere are private organizations,
healthcare providerorganizations which have created
modules for their employees.
So the revenue stream from themodules goes back to the vendor
and the NBCRNA never sees that.
And of course they don't haveany, a role that setting the
(09:23):
price for those.
Mike MacKinnon (09:24):
And so what is that initial fee for a vendor if
they choose to go down thatroute?
Dr Terry Wicks (09:30):
Well, that's a really great question, Mike.
You know, the initial last toreview a module for recognition
as$2,500 per module and thenthere's a$500 annual fee per
module to review that to ensurea currency of the module.
We are getting it at a point intime when a lot of those
original modules are going to beresubmitted for review, for
(09:50):
update and right now they arestill trying to determine at the
office with the most appropriatefee for that would be, and I
imagine it'll be closelyresemble what we've charged in
the past and of course we'rereally interested in, it's
covering our human resourcescosts and not really making a
profit on that.
Mike MacKinnon (10:06):
Is that a lifetime fee?
Basically you create a module,this is the cost and then from
there on in it's continues or isthere ultimately new fees to
maintain that?
Dr Terry Wicks (10:14):
I think that uh, the NBCRNA has required the
vendors update those modules ona periodic basis.
I think they have to bemodernized every four years and
they have to be resubmitted.
I don't know if there's adiscounted rate for resubmission
for our a renovated module or ifit's the same price, but it's
probably similar because thatwhole price point is set based
(10:36):
on the number of man hours andthe human resources required on
the part of the NBCRNA to reviewthe module.
Mike MacKinnon (10:42):
Right.
So basically you've covered whatthe CPC is and how it works.
I guess one of the questionsthat I hear a lot from members
is why did we need this change?
What was wrong with our originalprogram that it wasn't
sufficient enough to continue?
Because as you know, crns have along history and track record of
incredible safety.
And so if, if that was the case,why do we need this upgrade?
Dr Terry Wicks (11:03):
Yeah, well that's a great question Mike,
and I'll be honest with you, youare absolutely hit the nail on
the head.
There are very few healthcareprofessionals that have a track
record of safety and thatcompares to nurse anesthetist.
But what we do know is that inevery field of human endeavor,
uh, those people who areprobably in most need of
updating their practice orrenewing their skills, they're
(11:26):
probably least able toobjectively judge their own
skills.
And that's called the dunningKruger effect.
And it applies to lots ofdifferent domains, not just
health care but the use of humorwritings, sports, uh, ability to
tackle math problems.
So the interesting thing is, isthe least skilled are the most
likely to overestimate theirabilities, whereas the most
skilled people tend tounderestimate their abilities.
(11:48):
But that's really an aside.
You know, the driver was reallythose which credential the
NBCRNA to certify certain nurseanesthetist.
And that includes the NationalCouncil on certifying agencies
and the accrediting board perspecially nursing accreditation.
And those boards require acouple of things that are
(12:10):
important.
They require that ourrecertification model should
include a multimodal approachthat encourages individuals to
continue activities essentiallyto maintenance of knowledge and,
and continuing practice oftheir, their specialty also
stipulates that recertificationshould be time limited and
should last for no more thanfive years.
And then the final piece ofthat, which caused a lot of
(12:31):
consternation, is that thequestion was asked, well, you
know, I've been practicing for25 or 30 years, why should I be
grandfathered?
And the black and white print isbasically says that
grandfathering may have beenused before to satisfy initial
certification, but they insistedthat no longer be the case.
So our accrediting bodiesrequired for us to remain to be
(12:53):
a certifying agency that we makethose kinds of changes.
Mike MacKinnon (12:56):
Right?
So when it comes to that change,I think a lot of people look at
it and say, well look, if thischange doesn't predict clinical
competence, you know, you're notin any way, particularly testing
a crns ability to provideanesthesia safely, but simply
asking questions or reviewingmodules and then having a test.
So how would you respond tothose concerns that if it's not
(13:16):
going to predict clinicalconfidence, it's not doing
anything extra, what is thereason then that's what a lot of
people I think are asking.
Dr Terry Wicks (13:23):
Well, that's a really good question.
Of course, you and I both knowthat clinical competence really
encompasses a number of domains.
It's not only knowledge but it'salso judgment and decision
making.
And in addition to that,obviously you gotta dovetail
into that, you know, psychomotorskills, uh, and work ethic and
you know, ethical issues towardspractice.
What the NBC RNA recognizes isthat we can assess knowledge.
(13:47):
We're relatively easily, we knowthat that's a time proven
scientific fact and we can alsodovetail into that a degree of
evaluation of decision making.
But at that point then we wereentering into a real gray area
after that.
So what the NBC RNA is engagedin is, uh, several processes
which will change the NBCRNA andthe CPC over time.
(14:09):
Uh, we have a committee rightnow investigating ways in which
we can dovetail emulation intothe CPC.
And they are looking at thewhole spectrum of stimulation
from high fidelity patientsimulation to virtual reality.
And there's some evidence thatvirtual reality can be
beneficial in terms ofevaluating skills and decision
(14:30):
making.
And we are also have a committeethat's investigating the
experiences of othercertification bodies.
And new technologies for thedelivery of longitudinal
learning, which is very similarto the ASA Moca or the Moca two
that ASA members engaged in.
And there's some good evidencethat's accumulating when people
participate in Longitudinalalerting platforms, their
(14:51):
knowledge actually does increaseand that they perform better
over time.
So those are a couple of thingsthat the NBCRNA has got on the
front burner.
Uh, we're excited about them andwe're really looking forward to
seeing the results of thosecommittees work probably
delivered to our board withinthe next one to two years.
And those things will influencethe pathway that the NBCRNA
already takes in its researchvacation growth.
Mike MacKinnon (15:12):
All right, so this is an evolutionary process
and at some point in time downthe line with the expansion of
virtual reality and onlinesimulation, there will be some
direct clinical testing.
The way people think of clinicalcompetence isn't of course
knowledge base.
As you know, they think of it aswell, I do anesthesia every day
and my patients wake up and dogreat and no one complains.
So that's my clinicalcompetence.
(15:34):
At some point there'll be afunction of testing that down
the road with possible virtualreality or simulation.
Dr Terry Wicks (15:40):
Yeah, and it may be something that we offer as an
option.
Is this to substitute part ofthe CPC or it may be dovetailed
in CPC and total, it's hard totell at this point in time, but
I do want to emphasize, and Ithink sometimes gets lost that
even from the beginning, peoplelike Dr Chuck Bociano who was
one of the first presidents ofthe NBCRNA after the CPC was
(16:00):
launched and he wouldn't, whowas a past president of NBCRNA
and most recently Dr Bob Hawkinsall have said repeatedly that if
the CPC looks the same in 10years as it does today, then we
will have failed.
So we are continually looking atways to improve the platform to
make it better, to make it morerelevant, to reduce the burden
(16:22):
that it imposes on practicingCRNAs and to make it an avenue
for improving practice.
And one of the things that we'vegot on the, on the front burner
right now is we've engaged witha researcher to look at the long
term outcome changes that may berelated to participation in the
CPC by looking at historicaldata and then data moving
(16:43):
forward from 2016 when the CPCwas launched.
And so we're going to be able towin over time.
We're going to have anopportunity to look at those
data and see involvement in theCPC does make a difference in
patient outcomes, which isreally our first primary focus.
Mike MacKinnon (16:57):
Right.
I think, I think that alleviatessome of the concerns people have
in that there's, you know,there's an environment right now
where medicine and otherprofessions are looking at their
recertification process andeliminating some of these
components in favor of otheroptions or in some cases,
removal altogether.
And I think that, you know, whenpeople see that from our
profession, they look at it andsay, well, why?
(17:18):
Why do we have to do it ifthey're not doing it?
And so you know when you discussthe evidence, well, okay,
there's evidence.
They're suggesting that this hasthe potential to increase
knowledge over time.
And I think it's great that youguys are going to do some
research to show that over time.
How do you respond to thosepeople who say, well, if
medicine's not doing it, ourprimary competitor physician
anesthesiologists are, havemoved to Moca and have
(17:40):
eliminated their simulationexams, all that kind of stuff.
Why do we need to do it?
What separates us?
Dr Terry Wicks (17:46):
Well, I think one of the things that gets
overlooked is that by changingthe CPC from a pass fail exam to
changing their to basically anassessment with a performance
standard, we are really givingnurse anesthetist to take the
CPC and opportunity to get asnapshot of where their
knowledge deficits may lie.
And I can tell you from personalexperience, when I came to the
(18:08):
university and started doingdidactic teaching, things had
changed tremendously in the 25years since I graduated from
Madison.
You just go on.
And I've been giving continuingeducation lectures for my entire
career.
And you know, I think somepeople would argue maybe that
I'm kind of person that keepsup, but I was done how much I
had to learn myself in order toteach entry level crns.
(18:30):
So, you know, I think it's easyto lose track when you're
practicing every day at how muchthings do change.
And I think one obvious areawhere that is the movement
towards a limited or zero opioidadministration during January as
the easier early recovery fromanesthesia and surgery that's
new on the horizon.
Uh, I think there's a lot ofpractitioners that are still
(18:50):
finding out about, you know,drugs like Precedex and the role
of non-steroidals and reducingpain experiences
postoperatively, explosiveinterest in the use of ketamine
for depression, uh, and forchronic pain and PTSD.
So, you know, what we're hopingto do is give people a snapshot
of, Hey, here's the place whereI could probably improve my
practice and let them then gettargeted education to address
(19:14):
those shortcomings and theirknowledge.
So that's one value that wouldbe missing if we just eliminated
the CPC assessment altogether.
Mike MacKinnon (19:21):
Absolutely.
One of the concerns with theexam, going back to the exam
itself is although I think itwas an amazing move for the
NBCRNA to eliminate this wholepass fail, you know, cause there
was so many concerns aboutpeople's jobs and what would
happen to their certification intheir state.
But one of the things thatpeople are still concerned about
is the whole idea that, well,what if I pay, what if I fail my
first attempt around at thisexam?
(19:42):
So although it's not pass fail,there's going to be a number of
things that I maybe didn't dowell on and maybe it's a lot of
them.
If that happens, is thisinformation discoverable by
their employees or employers?
Can they, can they look in thewebsite and see, oh, you know,
Mike failed four modules and hehas to go back and do all this.
Is that something that theycould find out?
And I only mentioned thatbecause it could be a real
(20:02):
concern for people, you know, ifthey're working somewhere that
that could be found out and thenpossibly them in some way be
impacted by it.
Dr Terry Wicks (20:10):
Yeah.
And I think, I think that's alegitimate concern not only
from, for example, a privilegingand organizational level, which
obviously would be a concern oreven if that information were
disclosed at trial, uh, in anevaluation of someone's standard
of care.
And so the posture of the NBCRNA historically has been not to
release those results.
(20:31):
Certainly would not be availableto the public on NBC or any
website.
And I think it would probablytake a court ordered subpoena to
get those results that has notbeen tested in the past.
I know for the NCE exam, wedon't release those results
immediately to the takers of thetests themselves.
We do release them to theprogram directors after a
certain period of time.
(20:51):
And if the program directorwants to share those with the
students, they have thatopportunity.
But we take very seriously ourobligation to protect that kind
of information.
And as I said today, that hasnever been tested.
But our posture right now is notto in any way, shape or form
disclose that kind of privateinformation.
Mike MacKinnon (21:11):
Yeah, that makes sense.
It certainly is something thatI, I've been hearing a lot of
people course of really happythat it's no longer pass fail,
but very concerned about howthat could impact them later.
So as it, as the whole at CPC,uh, relates to the NBCRNA and
the increased costs for crnsover time for the MPC RNA CPC
(21:31):
exam and the modules, a lot ofpeople look at it and have the
criticism that, oh, you know,the NBC RNA is doing this just
to make more money to put moremoney in the coffers.
Uh, it's a new way to expand how, revenue stream with online
simulation all these things hadpossibly coming and of course,
the exam.
And how would the NBCRNA respondto that though?
(21:52):
That criticism,
Dr Terry Wicks (21:53):
you know, I think it's is a reasonable thing
for people to ask that questionbecause you know this is you
know the money that they have toinvest to sustain their working
career and I think it's areasonable thing for people to
take a hard look at that and askthe question.
Both I and John Preston who isone of our chief credentialing
officers take a close look atthis last year and based on our
(22:15):
estimation of what it cost inthe past to maintain
certification, including theactual cost that it's given to
the NBCRNA, the$55 or so or ayear, the cost of continuing
education and comparing all ofthose things across the board,
we believe that participation inthe CPC is going to be very
similar to what it costpreviously to maintain your
(22:38):
certification.
Particularly, you know, therewas a hard question asked about
what we were going to charge forthe CPC assessment itself.
And I, I read a comment onsocial media made by someone
that we could not possibly bringthis online for less than a
thousand dollars a charge perperson.
But, um, our finance departmenttook a hard look at the cost of
(22:59):
creating, maintaining andupdating the CPC assessment and
what it costs the NBCRNA toevaluate these other programs
that we've talked about,simulation, longitudinal
learning.
And we felt like we could bringthat to the market for$295 cover
our costs and have enough extrarevenue to sustain these other
programs that we'reinvestigating.
(23:20):
And so we're really happy thatwe got it down there because for
10 years we've been saying, hey,we think we can bring this test
forward for$300.
And so actually we gotunderneath that a little bit.
And the other thing is, is aswe've talked about in the past,
Mike, is that, you know, ourfinancial reserves are pretty
healthy and people look at thatand are critical of it.
But probably like most peoplewhose investment accounts have
(23:41):
done very well over the past 10years because of the growth in
the stock market and a good bitof our financial reserves are
also a direct result of our wiseinvestment policy and the good
fiduciary responsibility of ourboard of directors.
We use those resources to fundprojects like we've just talked
about the the simulationinvestigation and Longitudinal
(24:02):
assessment and also to provideprograms that generally don't
generate revenue streams for us,like the nonsurgical pain
management certification, whichis something that has cost the
NBCRNA at a loss throughout hislifetime.
And if we have the opportunity,the demand is there to provide
other certifications, whether itbe for regional anesthesia or
obstetrics or whateverpediatrics, whatever that market
(24:24):
asks for, we will look atkeeping the cost of those
programs if they are created atan absolute minimum and the way
that we can do that because wehave healthy financial reserves.
Mike MacKinnon (24:34):
Dovetailing back to the history, there's some
discussion I know about members,they seem to have some confusion
about the AANA, the NBCRNAconnectivity and how they're
related.
And I know originally the NBCRNAwas just part of the AANA and
was not autonomous, butsomething occurred at one point
in time in the history of theAna that resulted in the NBCRNA
being required to be autonomous.
(24:55):
What happened there?
Dr Terry Wicks (24:56):
Well, there's a couple of things.
I think that the Department ofEducation and the national
credentialing bodies recognizethat there has to be a laser
bright line between the folksthat are doing accreditation of
educational programs.
Those folks that are doingcertification and
recertification and the folksthat are providing advocacy for
the profession, so they have tobe separate.
(25:16):
In fact, the MDAs long time agowanted to take over education of
crns and that was one of thethings that prompted the
independent and autonomouscreation council on
accreditation to show that therewas that laser bright line and
also similar rationale was forproviding the autonomy and
independence of the NBCRNA or asit was known at that time, the
(25:37):
two separate councils.
And that's been very importantfor the profession because that
allows us to stand up and say,you know, no matter what our
advocate might say in Washingtonor at state legislatures or at
the boards of health or medicineor nursing, our credential is
defensible because it'sindependent.
It has a separate board ofdirectors that all I have is a
primary mission protection ofthe public through creating
(26:00):
credentialing processes thatpromote lifelong learning and a,
that is rock solid.
And that not only protects ourpatient, but it protects the
integrity and the longtermviability of the profession as
well.
Mike MacKinnon (26:13):
Yeah, I remember having those discussions with
you in the past.
Now, the one thing that, aboutthe NBCRNA is, is it's the only,
recredentialing agency forCRNAs.
And I think generally peoplefeel competition is good and
there's a discussion amongmembers that i t kind of ebbs
and wanes about, well, why don'twe have another body?
And if we did have another body,how would that look?
(26:35):
What are your thoughts on theidea of a, of a n additional
credentialing body to competewith t he N BCRNA?
Dr Terry Wicks (26:41):
Well, I think, um, I think that's an
interesting conversation to havebecause you know, the reality is
, uh, our credentialing body,the NBCRNA is a pretty complex
organization in terms of it's aresearch arm back to that.
It provides a certificationexamination for new graduates.
And in all the things that we'vetalked about with regards to the
CPC, no, as far as, you know, myperspective, and I think, you
(27:04):
know, the perspective of theNBCRNA is, you know, if somebody
else wants to create another, uh, certification organization or
recertification organization,you know, they're at liberty to
do that.
It'll still be a costlyundertaking, especially if you
want to recreate, at least inprinciple, a lot of the services
that the NBCRNA provides.
So if someone has the, you know,has the resources and the
(27:25):
motivation to do that, they arecertainly at liberty.
The one insight that I wouldoffer though is that a new
recertification body were formedand it provided a certification
process that was less stringentthan what is provided by the
NBCRNA.
You know, I have questions aboutwhether state legislatures and
boards of nursing andprivileging bodies at a local
level would recognize that.
(27:46):
And of course the other side ofthat coin is if a renewed, a new
certification body came intobeing that was more stringent
than the NBC RNA, you know, howmany crns would, uh, would sign
up for that.
So, you know, as I said, I didthis tire right ribbon around
it.
You know, the NBC alreadyrecognizes that anyone can do
that if they want to spend themoney and create the platform
(28:07):
and the framework and, and getthat thing recognized nationally
through all the accreditingbodies and have at it.
Mike MacKinnon (28:14):
And so when, when it comes to things like,
uh, for instance, the CPC exam,the modules, if a new
credentialing body came about,would they be able to do things
differently?
So what I'm saying is, is therecould be the same level of
standard, but maybe they didn'thave an exam in the way that the
NBCRNA currently envisions it.
Or they did the modules in adifferent way or they had a
(28:35):
separate sort of setup butconsidered maybe equally
stringent.
Can they do that?
Is that acceptable?
Dr Terry Wicks (28:41):
Oh sure they can do that.
They just have to get on thetrack and run through all the,
all the barriers and get itcreated
Mike MacKinnon (28:48):
and so, and the other side is I know that the
NBCRNA and the AANA have arecognition agreement.
And so how does that recognitionagreement impact a new
credentialing body?
Let's say the AANP wasapproached and they said, sure,
we'll take it over.
How does that impact therelationship with the AANA and
NBCRNA?
Dr Terry Wicks (29:06):
Well, I think the AANA NBCRNA have done a
really a lot of very productivework over the past seven or
eight years to create acollegial relationship that
recognizes their separatemission towards the public and
towards the CRNA practice.
We feel as a board that we're ata point now where we really have
a good dialogue that goes onconstantly with the AANA board
(29:29):
of directors.
Our presidents talk regularly.
We have liaison between the twoboards that attend their
individual board meetings andthey have a frequent conference
calls.
If we have something that's onthe front burner that we think
the AANA board would like toknow about before, you know, it
goes public, we make an effortto get that out to them.
So if another credentialing bodywould come along, uh, you know,
(29:50):
they would have to go through asimilar process to develop a
relationship with any board ofdirectors and that would be a
challenge for them.
But you know that that's apossibility.
Mike MacKinnon (29:58):
And specifically that recognition agreement
recognizes the NBCRNA is theonly one by the AANA currently
until, until the 10 year renewalpoint.
Right?
Is that correct?
Dr Terry Wicks (30:08):
I believe that is correct.
Yeah.
Mike MacKinnon (30:10):
dovetailing onto the simulation, we talked about
that a little bit already.
You know, I think everyonecompares anesthesia to the
airline industry.
We talk about it all the time.
There's lots of comparisons evenwithin our textbooks.
And the airline industry has ofcourse done a fantastic job of
simulation training andrecurrent simulation training
all the time.
And there is a group of CRNAsthat say, well, you know, why
(30:32):
have an exam?
Let's just have a simulationexam, which really does test
everything that's going on, atleast the snapshots of the
biggest things.
What are the barriers tocreating that sort of a
simulation exam set up today?
Dr Terry Wicks (30:45):
Well, probably the number one is price.
It's an expensive undertaking toadminister rigorous stimulation.
Even if we just looked atcritical incident management in
the operating room, that mightbe a one or a two day process.
And so you can imagine running a54,000 CRNAs through that over
the course of a couple of years.
It would be pretty daunting.
(31:06):
The other piece of that istravel.
And you know, for our folks thatlive out in the west of the
Mississippi, uh, independentpracticing CRNAs, practicing
critical access hospitals, folksthat practice in, in areas of
the country where a simulationcenter might be day's drive
away, there's a potential forlost income, not only lost
income, but the cost of havingsomebody come in and cover for
(31:28):
them while they're gone.
And the other thing is thatthere's the specter of what if
you go to the Sim Center and youdon't do well, what do we do
with you then do we just say,well you can't practice until
you come back and do that again.
So there are lots of financialand logistical and practice
issues that really have to beresolved before, you know, we
would engage in a system ofsystematic high fidelity patient
(31:49):
simulation as a criteria forcore recertification.
So that technology is young andthings are changing constantly.
So there may be an opportunityto do virtual reality at some
point a remotely they could helpsatisfy that.
But to the analogy with theairline industry, there is no
doubt whatsoever that highfidelity simulation in the
(32:09):
airline industry has contributeddramatically to traveler's
safety.
And I would be pretty reluctantto get in an airplane where the,
where the pilot or copilothadn't undergone that kind of
rigorous critical eventtraining.
So that's something we've got tolook at in the long run.
You know, there are now prettyconvincing of published evidence
(32:30):
to support using a cognitive aidin the operating room to help
manage crises.
So that's another avenue that wewant to take a look at, line
down the road if, if that has aplace in credentialing or with
simulation.
So it's a wide open landscape.
So you know, we've got some workto do to see if there's a place
for that.
Mike MacKinnon (32:46):
Oh, excellent answer.
The NBCRNA, hasn't really said awhole lot about types of
practice models or anything likethat or how they feel about
them.
And as we know, CRNAs workingprobably three main practice
models, one in an anesthesiacare team with physician
anesthesiologists, often in amedical direction model, one to
four style or you know,collaborative practice where
(33:07):
everyone's in their own room orthere may be just one physician
for 20, 30, CRNAs.
And then of course anindependent practice style where
they're working to full scope ofpractice and, managing the cases
day to day and doing everyportion of that pre anesthetic
to post anesthetic process.
One of the questions is how hasthe NBRNA supported that full
scope of practice?
(33:28):
Kind of, you know, the CRNAs whoare all by themselves or with a
CRNA group doing this entirerange of things.
In terms of recertification,what things have, has the NBCRNA
already done or what plans maythere be to expand that sort of
offering to that group ofpeople?
Dr Terry Wicks (33:44):
Well I think that probably the most prominent
piece of evidence to show thatsupport was the creation of the
nonsurgical pain managementcertification course.
That's a pretty complex in ahigh level area of practice, but
it's one where particularlyCRNAs in the rural area
absolutely needed their support.
You know, the NBCRNA tries toprovide good information to the
(34:04):
council on accreditation and tothe AANA where appropriate to
help them in their advocacyefforts.
The NBCRNA specifically kind oftakes a, you know, an arms
length distance from a lot ofthe political charged
discussions that take place asfar as how CRNAs are able to
practice or in what areas you'reable to practice.
Now our main focus is makingsure that CRNAs keep their
(34:26):
knowledge up to date and thatour certification process really
meets the highest standards ofthe contemporary recertification
industry.
It's always going to be achallenge to remain apolitical
for the NBCRNA, but you'llalways be that resource for the
or for the AANA, to provide theinformation that we can to
(34:49):
support the CRNA practice.
Mike MacKinnon (34:51):
Well part of the reason I ask is because you
know, the NBCRNA has thismission to promote patient
safety and I, you know, as weare well aware, based on the
evidence, all available evidenceis CRNAs are safe in any model.
It doesn't matter what model youwork in.
And with this a continuous andconstant rapidly expanding full
scope of CRNA practice costsacross the country, both in
(35:12):
autonomous style models andindependent models and
anesthesia care team, sort of onthe wane, what actions has or
does the NBCRNA plan toundertake to help support that
model?
Because obviously, you know, ifthere's more and more CRNAs in
that kind of a model, there's anexpansion of the needs of those
CRNAs both in recertificationand certification and an
education.
(35:32):
And so with your certificationportion, how would you do that
best?
Dr Terry Wicks (35:35):
Well, I think we've been asked by a couple of
different interested CRNAs toevaluate the possibility of
providing a, perhaps inobstetrics certification
credential or a regionalanesthesia recognition.
So we have to look at thosethings very carefully,
recognizing that the possibilityexists that by creating that
sort of a recognition that it'spossible we could even box CRNAs
(35:59):
out from those areas ofpractice.
So that's something that we haveto look at very, very carefully.
But other than that, you know,we really have stayed pretty
well clear of the, of thepolitical discord out there in
the healthcare industry andreally tried to sustain our
focus right on there oncertification recertification.
Mike MacKinnon (36:15):
So at this point there's nothing, there's nothing
particularly specific at theNBCRNA does to support that full
scope of practice other than therecertification is broad.
Dr Terry Wicks (36:24):
Right?
It's really kind of outside ofour wheel house.
Mike MacKinnon (36:27):
Okay.
And then probably one of themost controversial things that's
happened in our professionrecently is the AANAs acceptance
of the, of this new title, anurse anesthesiologist.
And so that's givencontroversial both in a
political way, even internally,uh, and outside externally.
What is the NBCRNAs position onthat and how or what would the
(36:48):
NBCRNA be able to do to supportthat moving forward as it grows
in popularity?
Assuming it does.
Dr Terry Wicks (36:54):
So what we would have to do, uh, is to really
engaged in a, a, in a knowledgebased discussion what the NBCRNA
wants to do.
We have not undertaken thatformal discussion at a board
level.
And so the headline is that wehaven't considered that,
however, w e're not ignorant ofwhat's going on i n, in the
anesthesia community.
(37:15):
And you know, recognize thatAANA board of directors has
allowed CRNA's where permissibleto use t he descriptor, a nurse
anesthesiologist.
And I know that some boards ofnursing have recognized that.
S o I think what we're waitingfor before we really engage in a
discussion about that on apolicy level or as a posture is
to wait until we see where thetide is taking us.
(37:38):
U h, I know that there was abylaws change proposal that was
initially intended to be broughtforward t oday i n a business
meeting that was initially goingto ask for a change in the name
of the organization.
And there seemed to be a lot ofdivision about that.
And so that was withdrawn.
So we are really taking a couplesteps back.
We're g oing t o kind of watchwhere that goes.
Obviously i f that gained somemomentum, we're going to have to
(38:01):
look at what boards of nursingare designing, what state
legislators are deciding, u h,in terms of recognition of that
title.
A nd we'll kind of go fromthere.
Mike MacKinnon (38:09):
And so what, what would that look like?
Does it change therecertification exam title?
Does it change the process bythe, the certification is there
now two certifications, CRNAanesthetist, CRNA
anesthesiologist, you know,looking down the road in the
future.
If this got very popular and youguys decided that as an NBCRNA
you had to expand this offeringor do this and re-certification,
(38:31):
what, what does that look like?
Are there two different titles?
Is there one combined?
Dr Terry Wicks (38:36):
Well I think what we would have to do is go
back to our accrediting body,the National Council on
certifying agencies and theaccreditation board for nursing
specialty accreditation and havea conversation with them and
possibly even go as far up theline as the institute for
credentialing excellence and seewhat stipulations that would
have to be satisfied if we were,if we embarked on a change.
(38:58):
My guess is is that at leastinitially, and this is just
speculation, that there might bea period of time when when both
are recognized, but again thatI'm guessing is a little ways
down the line and obviously wewould have to have an intense
and a deep dive conversation ata board level about the
direction we want it to go.
Mike MacKinnon (39:16):
Excellent.
And so we basically come to theend of the interview.
Terry, I appreciate you beinghere.
It has been great.
A great conversation.
As usual.
What last things would you leaveour audience with about the
NBCRNA, the CPC and anythingthat they should know?
Dr Terry Wicks (39:33):
Sure.
I think that's a great question,Mike.
Thank you for asking that.
Uh, every time I have anopportunity to engage with CRNAs
on social media or face to faceat meetings or even in
individual institution where Ihappen to have a chance to visit
with CRNAs, I asked them to goto the NBCRNA website.
There is just an enormous wealthof resources there.
(39:55):
There's guidance, there's anavenue there to look at your
progress towards recertificationand get a graphic representation
of what you need to do.
Call the office.
Uh, our staff is availableseven, well not seven days a
week.
available five days a week.
They always answer the phone andif they don't have an answer for
you, they'll get one.
Reach out to us.
We are, we are at statemeetings, we're at private CE
(40:17):
vendors meetings trying to makeour presence and you know, ask
us questions, go to the website,get some additional information.
And, uh, we really hope thatpeople recognize that we're
working on their behalf as wellas on the behalf of the patient.
Mike MacKinnon (40:30):
Well, thank you so much, Dr Wicks.
I appreciate your time and havea great day.
Dr Terry Wicks (40:35):
Okay, thank you Dr MacKinnon.
I appreciate it.
OUTRO (40:38):
That's all for this episode of anesthesia
deconstructed.
For more information based ontoday's discussion, be sure to
visit us@anesthesia-deconstructed.com
you'll also gain access to ourblogs, editorials, and more
resources to keep you updated onthe science, politics, and
realities of today's medicalindustry.
That'sanesthesia-deconstructed.com.
Popular Podcasts
United States of Kennedy
United States of Kennedy is a podcast about our cultural fascination with the Kennedy dynasty. Every week, hosts Lyra Smith and George Civeris go into one aspect of the Kennedy story.
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com