CRNA Recertification, the NBCRNA and the CPC with Dr. Terry Wicks

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. 

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• 10:42 [Ad] OWNR OPS Podcast
• 11:19 (Cont.) CRNA Recertification, the NBCRNA and the CPC with Dr. Terry Wicks

Transcript

INTRO: 0:01

Welcome to anesthesia deconstructed science politics realities. Listen, as medical professionals join industry expert, Mike MacKinnon to discuss the latest science and medical advancements, the effects of our political climate and the realities of today's changing healthcare environment. Let's get started with your host, Mike MacKinnon.

Mike MacKinnon: 0:27

Hello everyone and welcome to the very first episode of anesthesia deconstructed science politics and realities podcast. My name is Michael MacKinnon. I'm going to be your host. I've been a CRNA for about 10 years and I will be bringing you through the process of all the stories and interviews over the coming episodes. On this episode, we're going to be talking to Dr. Terry Wicks, who is the incoming NBCRNA president about the continuing professional certification program, otherwise known as the CPC, which is highly controversial. Today's guest is going to be Dr. Terry Wicks, who is the incoming president of the NBCRNA, which of course is the recertification body that recertify CRNAs. Dr Wicks began his career 20 years ago where he graduated in 1986 from the U s army anesthesia program with a master's degree and he also went on to receive his doctorate. Just this last year and maintains an active clinical practice in North Carolina. In addition to that, Dr Wicks was the American Association of Nurse Anesthetists President in 2006 2007 in his professional life. He's currently a professor in the nurse anesthesia program at the University of North Carolina, Greensboro and he is a founding member of the rock band volatile agents, which is his true passion he tells me, so sit down, enjoy your ride in your vehicle, listen to our podcast. This is going to be an interesting episode, important for CRNAs. Get the information. Let's get it on. Welcome Dr Terry Wicks for the show and congratulations on your doctorate!

Dr Terry Wicks: 2:09

Yeah, thank you very much. It was hard work, but obviously I've been paying it off. I got a job teaching at UNC g and so I'm where I want to be in my career right now.

Mike MacKinnon: 2:18

Excellent. That's all you can hope for. So I mean, as you know, the rollout of the NBCRNA CPC program has been controversial since its beginning in Boston when it was originally announced. There's a large group of members that are very concerned about what's happening, what's going to happen. But I think in order to understand it best, we kind of have to set the stage with the history of the NBCRNA and you know, how it works, how it interacts and functions with the Coa, the AANA and members. Cause I think people are pretty unclear as to the difference between the NBCRNA, the AANA and the coa. Can you enlighten us to that a little bit?

Dr Terry Wicks: 2:51

Absolutely. And you know, I understand, uh, you know, where there's some confusion because even 10 years ago when I was on the board of directors of the, and hey, I lacked the kind of clarity that I think is important for AANA members to have when they're looking at these relatively cooperative, yet administratively autonomously, these agencies that are separate by financially and through their, through leadership, we have to turn the clock back. We have to look all the way back to 1975 when the AANA members, I had a business meeting approved establishment of the council to oversee accreditation of their programs and certification process for nurse anesthetist. Both those entering the profession and a in a couple of years later for those who would be recertified. And so now that process is as most seasoned sons CRNAs know is well over 50 years old and hadn't really changed much since its outset. And then about 10 or 12 years ago in the process of renegotiating the relationships between AANA and the council on certification and recertification, uh, it became obvious that the organizations had wrote apart, at least in the sense that their missions were clearly separate day AANA obviously being the political advocacy organization and the council on certification of nursing really focusing its attention on certifying new entrants to the profession and the council and recertification for maintaining their credential over time. And a decision was made by those two councils to form a corporation, which they renamed the NBCRNA, the national board for certification and recertification of nurse anesthetist. And that really was sort of that laser bright line that separated those two functions of certification recertification from the broader political advocacy role of the Ana. Now what they did very shortly after that starting I think in about 2008 as they started to look at their the recertification process and the changes that were taking place in the recertification community, not just nursing but organized medicine, we're wrestling with trying to find a way to update that with the current recertification standard and after doing a professional practice analysis where AANA members determined those things that were most important to know in order to practice safely irrespective of their practice setting. The CPC was conceived and composed of several parts. The first part of course is familiar to most and that is continuing education credits, but the added component was that there was a going to be a requirement for those continuing education credits to be assessed in order to be recognized, at least for the classification that we call class a. The CPC also contains an opportunity for CRNAs to be recognized for doing a service to the health care industry and to the organizations and educating uh, ancillary and allied health professionals and get credit for those educational efforts as well as serving on committees and doing community work. Even even taking part in mission projects. And those are the class B credits and of course they don't have to be prior approved and there are very simple and in terms of what they require in terms of documentation. The other two pieces that really do seem to cause a lot of confusion are the modules and of course the CPC assessment. The modules originally were going to be required every four years and they covered the areas of technology, pharmacology, airway management and physiology and pathophysiology. And those four domains overlap with those areas where CRNAs identified being most important for safe practice. The intent of the modules is to keep CRNAs up to date with emerging technology and information in the anesthesia community. And they derive their content from anesthesia research that's been published. The vendors have the modules have the ability to provide whatever baseline and background information to support the new information that they choose to, but the key is is that whenever a module is approved or recognized by the NBCRNA, there are specific objectives that that vendor has to address in their a module or provide information to support their decision not to cover that. The beauty of those modules as they satisfy class A credit and I think compared to what it costs to get other classes traveling to meetings and paying entry fees and staying in hotel and restaurant class A credits on the modules are relatively inexpensive and maybe a few hundred dollars from the AANA to get packages that provide you with them. We're about 17 or 19 class eight credits, which is really a bargain, but one of my heroes called it the elephant in the room of course is the CPC assessment and a course. I think a lot of the anxiety surrounding that CPC assessment is when it was originally rolled out, it was framed as a pass fail test. And of course me like everyone else that his concern would be, you know, aware of the threat that if you fail to be successful on the examination as it was originally conceived, one could possibly have in jeopardy their ability to practice as the CRNA and support their family.

Mike MacKinnon: 7:57

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, are these third party companies, contributing revenue to the NBCRNA or are they doing it on their own? What is the process for that third party company in order to be able to be allowed or certified to, to provide these modules?

Dr Terry Wicks: 8:19

That's a great question. Originally we set specific objectives for information content that the module had to satisfy in order to be recognized by the NBC RNA. The NBCRNA does charge a fee for reviewing the module to ensure that the content is contemporary and that it satisfies those objectives. But at that point, the NBC or RNA basically is taking a hands off approving organizations like the AANA. We'll look at the module and determine how many continuing education credits it will award for that module. The vendor themselves set the price for the module, and so the NBCRNA gets no money from the marketing of the module. There are state associations that have submitted modules for recognition. A, of course obviously does, and there are private organizations, healthcare provider organizations which have created modules for their employees. So the revenue stream from the modules goes back to the vendor and the NBCRNA never sees that. And of course they don't have any, a role that setting the price for those.

Mike MacKinnon: 9:24

And so what is that initial fee for a vendor if they choose to go down that route?

Dr Terry Wicks: 9:30

Well, that's a really great question, Mike. You know, the initial last to review a module for recognition as$2,500 per module and then there's a$500 annual fee per module to review that to ensure a currency of the module. We are getting it at a point in time when a lot of those original modules are going to be resubmitted for review, for update and right now they are still trying to determine at the office with the most appropriate fee for that would be, and I imagine it'll be closely resemble what we've charged in the past and of course we're really interested in, it's covering our human resources costs 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 is there ultimately new fees to maintain that?

Dr Terry Wicks: 10:14

I think that uh, the NBCRNA has required the vendors update those modules on a periodic basis. I think they have to be modernized every four years and they have to be resubmitted. I don't know if there's a discounted rate for resubmission for our a renovated module or if it's the same price, but it's probably similar because that whole price point is set based on the number of man hours and the human resources required on the part of the NBCRNA to review the module.

Mike MacKinnon: 10:42

Right. So basically you've covered what the CPC is and how it works. I guess one of the questions that I hear a lot from members is why did we need this change? What was wrong with our original program that it wasn't sufficient enough to continue? Because as you know, crns have a long history and track record of incredible safety. And so if, if that was the case, why do we need this upgrade?

Dr Terry Wicks: 11:33

Yeah, well that's a great question Mike, and I'll be honest with you, you are absolutely hit the nail on the head. There are very few healthcare professionals that have a track record of safety and that compares to nurse anesthetist. But what we do know is that in every field of human endeavor, uh, those people who are probably in most need of updating their practice or renewing their skills, they're probably least able to objectively judge their own skills. And that's called the dunning Kruger effect. And it applies to lots of different domains, not just health care but the use of humor writings, sports, uh, ability to tackle math problems. So the interesting thing is, is the least skilled are the most likely to overestimate their abilities, whereas the most skilled people tend to underestimate their abilities. But that's really an aside. You know, the driver was really those which credential the NBCRNA to certify certain nurse anesthetist. And that includes the National Council on certifying agencies and the accrediting board per specially nursing accreditation. And those boards require a couple of things that are important. They require that our recertification model should include a multimodal approach that encourages individuals to continue activities essentially to maintenance of knowledge and, and continuing practice of their, their specialty also stipulates that recertification should be time limited and should last for no more than five years. And then the final piece of that, which caused a lot of consternation, is that the question was asked, well, you know, I've been practicing for 25 or 30 years, why should I be grandfathered? And the black and white print is basically says that grandfathering may have been used before to satisfy initial certification, but they insisted that no longer be the case. So our accrediting bodies required for us to remain to be a certifying agency that we make those kinds of changes.

Mike MacKinnon: 13:26

Right? So when it comes to that change, I think a lot of people look at it and say, well look, if this change doesn't predict clinical competence, you know, you're not in any way, particularly testing a crns ability to provide anesthesia safely, but simply asking questions or reviewing modules and then having a test. So how would you respond to those concerns that if it's not going to predict clinical confidence, it's not doing anything extra, what is the reason then that's what a lot of people I think are asking.

Dr Terry Wicks: 13:52

Well, that's a really good question. Of course, you and I both know that clinical competence really encompasses a number of domains. It's not only knowledge but it's also judgment and decision making. And in addition to that, obviously you gotta dovetail into that, you know, psychomotor skills, uh, and work ethic and you know, ethical issues towards practice. What the NBC RNA recognizes is that we can assess knowledge. We're relatively easily, we know that that's a time proven scientific fact and we can also dovetail into that a degree of evaluation of decision making. But at that point then we were entering into a real gray area after that. So what the NBC RNA is engaged in is, uh, several processes which will change the NBCRNA and the CPC over time. Uh, we have a committee right now investigating ways in which we can dovetail emulation into the CPC. And they are looking at the whole spectrum of stimulation from high fidelity patient simulation to virtual reality. And there's some evidence that virtual reality can be beneficial in terms of evaluating skills and decision making. And we are also have a committee that's investigating the experiences of other certification bodies. And new technologies for the delivery of longitudinal learning, which is very similar to the ASA Moca or the Moca two that ASA members engaged in. And there's some good evidence that's accumulating when people participate in Longitudinal alerting platforms, their knowledge actually does increase and that they perform better over time. So those are a couple of things that the NBCRNA has got on the front burner. Uh, we're excited about them and we're really looking forward to seeing the results of those committees work probably delivered to our board within the next one to two years. And those things will influence the pathway that the NBCRNA already takes in its research vacation growth.

Mike MacKinnon: 15:42

All right, so this is an evolutionary process and at some point in time down the line with the expansion of virtual reality and online simulation, there will be some direct clinical testing. The way people think of clinical competence isn't of course knowledge base. As you know, they think of it as well, I do anesthesia every day and my patients wake up and do great and no one complains. So that's my clinical competence. At some point there'll be a function of testing that down the road with possible virtual reality or simulation.

Dr Terry Wicks: 16:09

Yeah, and it may be something that we offer as an option. Is this to substitute part of the CPC or it may be dovetailed in CPC and total, it's hard to tell at this point in time, but I do want to emphasize, and I think sometimes gets lost that even from the beginning, people like Dr Chuck Bociano who was one of the first presidents of the NBCRNA after the CPC was launched and he wouldn't, who was a past president of NBCRNA and most recently Dr Bob Hawkins all have said repeatedly that if the CPC looks the same in 10 years as it does today, then we will have failed. So we are continually looking at ways to improve the platform to make it better, to make it more relevant, to reduce the burden that it imposes on practicing CRNAs and to make it an avenue for improving practice. And one of the things that we've got on the, on the front burner right now is we've engaged with a researcher to look at the long term outcome changes that may be related to participation in the CPC by looking at historical data and then data moving forward from 2016 when the CPC was launched. And so we're going to be able to win over time. We're going to have an opportunity to look at those data and see involvement in the CPC does make a difference in patient outcomes, which is really our first primary focus.

Mike MacKinnon: 17:27

Right. I think, I think that alleviates some of the concerns people have in that there's, you know, there's an environment right now where medicine and other professions are looking at their recertification process and eliminating some of these components in favor of other options or in some cases, removal altogether. And I think that, you know, when people see that from our profession, they look at it and say, well, why? Why do we have to do it if they're not doing it? And so you know when you discuss the evidence, well, okay, there's evidence. They're suggesting that this has the potential to increase knowledge over time. And I think it's great that you guys are going to do some research to show that over time. How do you respond to those people who say, well, if medicine's not doing it, our primary competitor physician anesthesiologists are, have moved to Moca and have eliminated their simulation exams, all that kind of stuff. Why do we need to do it? What separates us?

Dr Terry Wicks: 18:15

Well, I think one of the things that gets overlooked is that by changing the CPC from a pass fail exam to changing their to basically an assessment with a performance standard, we are really giving nurse anesthetist to take the CPC and opportunity to get a snapshot of where their knowledge deficits may lie. And I can tell you from personal experience, when I came to the university and started doing didactic teaching, things had changed tremendously in the 25 years since I graduated from Madison. You just go on. And I've been giving continuing education lectures for my entire career. And you know, I think some people would argue maybe that I'm kind of person that keeps up, but I was done how much I had to learn myself in order to teach entry level crns. So, you know, I think it's easy to lose track when you're practicing every day at how much things do change. And I think one obvious area where that is the movement towards a limited or zero opioid administration during January as the easier early recovery from anesthesia and surgery that's new on the horizon. Uh, I think there's a lot of practitioners that are still finding out about, you know, drugs like Precedex and the role of non-steroidals and reducing pain experiences postoperatively, explosive interest in the use of ketamine for depression, uh, and for chronic pain and PTSD. So, you know, what we're hoping to do is give people a snapshot of, Hey, here's the place where I could probably improve my practice and let them then get targeted education to address those shortcomings and their knowledge. So that's one value that would be missing if we just eliminated the CPC assessment altogether.

Mike MacKinnon: 19:51

Absolutely. One of the concerns with the exam, going back to the exam itself is although I think it was an amazing move for the NBCRNA to eliminate this whole pass fail, you know, cause there was so many concerns about people's jobs and what would happen to their certification in their state. But one of the things that people are still concerned about is the whole idea that, well, what if I pay, what if I fail my first attempt around at this exam? So although it's not pass fail, there's going to be a number of things that I maybe didn't do well on and maybe it's a lot of them. If that happens, is this information discoverable by their employees or employers? Can they, can they look in the website and see, oh, you know, Mike failed four modules and he has to go back and do all this. Is that something that they could find out? And I only mentioned that because it could be a real concern for people, you know, if they're working somewhere that that could be found out and then possibly them in some way be impacted by it.

Dr Terry Wicks: 20:39

Yeah. And I think, I think that's a legitimate concern not only from, for example, a privileging and organizational level, which obviously would be a concern or even if that information were disclosed at trial, uh, in an evaluation of someone's standard of care. And so the posture of the NBC RNA historically has been not to release those results. Certainly would not be available to the public on NBC or any website. And I think it would probably take a court ordered subpoena to get those results that has not been tested in the past. I know for the NCE exam, we don't release those results immediately to the takers of the tests themselves. We do release them to the program directors after a certain period of time. And if the program director wants to share those with the students, they have that opportunity. But we take very seriously our obligation to protect that kind of information. And as I said today, that has never been tested. But our posture right now is not to in any way, shape or form disclose that kind of private information.

Mike MacKinnon: 21:40

Yeah, that makes sense. It certainly is something that I, I've been hearing a lot of people course of really happy that it's no longer pass fail, but very concerned about how that could impact them later. So as it, as the whole at CPC, uh, relates to the NBCRNA and the increased costs for crns over time for the MPC RNA CPC exam and the modules, a lot of people look at it and have the criticism that, oh, you know, the NBC RNA is doing this just to make more money to put more money in the coffers. Uh, it's a new way to expand how, revenue stream with online simulation all these things had possibly coming and of course, the exam. And how would the NBCRNA respond to that though? That criticism,

Dr Terry Wicks: 22:22

you know, I think it's is a reasonable thing for people to ask that question because you know this is you know the money that they have to invest to sustain their working career and I think it's a reasonable thing for people to take a hard look at that and ask the question. Both I and John Preston who is one of our chief credentialing officers take a close look at this last year and based on our estimation of what it cost in the past to maintain certification, including the actual cost that it's given to the NBCRNA, the$55 or so or a year, the cost of continuing education and comparing all of those things across the board, we believe that participation in the CPC is going to be very similar to what it cost previously to maintain your certification. Particularly, you know, there was a hard question asked about what we were going to charge for the CPC assessment itself. And I, I read a comment on social media made by someone that we could not possibly bring this online for less than a thousand dollars a charge per person. But, um, our finance department took a hard look at the cost of creating, maintaining and updating the CPC assessment and what it costs the NBCRNA to evaluate these other programs that we've talked about, simulation, longitudinal learning. And we felt like we could bring that to the market for$295 cover our costs and have enough extra revenue to sustain these other programs that we're investigating. And so we're really happy that we 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 got underneath that a little bit. And the other thing is, is as we've talked about in the past, Mike, is that, you know, our financial reserves are pretty healthy and people look at that and are critical of it. But probably like most people whose investment accounts have done very well over the past 10 years because of the growth in the stock market and a good bit of our financial reserves are also a direct result of our wise investment policy and the good fiduciary responsibility of our board of directors. We use those resources to fund projects like we've just talked about the the simulation investigation and Longitudinal assessment and also to provide programs that generally don't generate revenue streams for us, like the nonsurgical pain management certification, which is something that has cost the NBCRNA at a loss throughout his lifetime. And if we have the opportunity, the demand is there to provide other certifications, whether it be for regional anesthesia or obstetrics or whatever pediatrics, whatever that market asks for, we will look at keeping the cost of those programs if they are created at an absolute minimum and the way that we can do that because we have healthy financial reserves.

Mike MacKinnon: 25:03

Dovetailing back to the history, there's some discussion I know about members, they seem to have some confusion about the AANA, the NBCRNA connectivity and how they're related. And I know originally the NBCRNA was just part of the AANA and was not autonomous, but something occurred at one point in time in the history of the Ana that resulted in the NBCRNA being required to be autonomous. What happened there?

Dr Terry Wicks: 25:25

Well, there's a couple of things. I think that the Department of Education and the national credentialing bodies recognize that there has to be a laser bright line between the folks that are doing accreditation of educational programs. Those folks that are doing certification and recertification and the folks that are providing advocacy for the profession, so they have to be separate. In fact, the MDAs long time ago wanted to take over education of crns and that was one of the things that prompted the independent and autonomous creation council on accreditation to show that there was that laser bright line and also similar rationale was for providing the autonomy and independence of the NBCRNA or as it was known at that time, the two separate councils. And that's been very important for the profession because that allows us to stand up and say, you know, no matter what our advocate might say in Washington or at state legislatures or at the boards of health or medicine or nursing, our credential is defensible because it's independent. It has a separate board of directors that all I have is a primary mission protection of the public through creating credentialing processes that promote lifelong learning and a, that is rock solid. And that not only protects our patient, but it protects the integrity and the longterm viability of the profession as well.

Mike MacKinnon: 26:42

Yeah, I remember having those discussions with you in the past. Now, the one thing that, about the NBCRNA is, is it's the only, recredentialing agency for CRNAs. And I think generally people feel competition is good and there's a discussion among members that i t kind of ebbs and wanes about, well, why don't we have another body? And if we did have another body, how would that look? What are your thoughts on the idea of a, of a n additional credentialing body to compete with t he N BCRNA?

Dr Terry Wicks: 27:10

Well, I think, um, I think that's an interesting conversation to have because you know, the reality is, uh, our credentialing body, the NBCRNA is a pretty complex organization in terms of it's a research arm back to that. It provides a certification examination for new graduates. And in all the things that we've talked about with regards to the CPC, no, as far as, you know, my perspective, and I think, you know, the perspective of the NBCRNA 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 costly undertaking, especially if you want to recreate, at least in principle, a lot of the services that the NBCRNA provides. So if someone has the, you know, has the resources and the motivation to do that, they are certainly at liberty. The one insight that I would offer though is that a new recertification body were formed and it provided a certification process that was less stringent than what is provided by the NBCRNA. You know, I have questions about whether state legislatures and boards of nursing and privileging bodies at a local level would recognize that. And of course the other side of that coin is if a renewed, a new certification body came into being that was more stringent than the NBC RNA, you know, how many crns would, uh, would sign up for that. So, you know, as I said, I did this tire right ribbon around it. You know, the NBC already recognizes that anyone can do that if they want to spend the money and create the platform and the framework and, and get that thing recognized nationally through all the accrediting bodies and have at it.

Mike MacKinnon: 28:44

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 there could be the same level of standard, but maybe they didn't have an exam in the way that the NBCRNA currently envisions it. Or they did the modules in a different way or they had a separate sort of setup but considered maybe equally stringent. Can they do that? Is that acceptable?

Dr Terry Wicks: 29:11

Oh sure they can do that. They just have to get on the track and run through all the, all the barriers and get it created

Mike MacKinnon: 29:18

and so, and the other side is I know that the NBCRNA and the AANA have a recognition agreement. And so how does that recognition agreement impact a new credentialing body? Let's say the AANP was approached and they said, sure, we'll take it over. How does that impact the relationship with the AANA and NBCRNA?

Dr Terry Wicks: 29:36

Well, I think the AANA NBCRNA have done a really a lot of very productive work over the past seven or eight years to create a collegial relationship that recognizes their separate mission towards the public and towards the CRNA practice. We feel as a board that we're at a point now where we really have a good dialogue that goes on constantly with the AANA board of directors. Our presidents talk regularly. We have liaison between the two boards that attend their individual board meetings and they have a frequent conference calls. If we have something that's on the front burner that we think the AANA board would like to know about before, you know, it goes public, we make an effort to get that out to them. So if another credentialing body would come along, uh, you know, they would have to go through a similar process to develop a relationship with any board of directors and that would be a challenge for them. But you know that that's a possibility.

Mike MacKinnon: 30:28

And specifically that recognition agreement recognizes the NBCRNA is the only one by the AANA currently until, until the 10 year renewal point. Right? Is that correct?

Dr Terry Wicks: 30:38

I believe that is correct. Yeah.

Mike MacKinnon: 30:40

dovetailing onto the simulation, we talked about that a little bit already. You know, I think everyone compares anesthesia to the airline industry. We talk about it all the time. There's lots of comparisons even within our textbooks. And the airline industry has of course done a fantastic job of simulation training and recurrent simulation training all the time. And there is a group of CRNAs that say, well, you know, why have an exam? Let's just have a simulation exam, which really does test everything that's going on, at least the snapshots of the biggest things. What are the barriers to creating that sort of a simulation exam set up today?

Dr Terry Wicks: 31:15

Well, probably the number one is price. It's an expensive undertaking to administer rigorous stimulation. Even if we just looked at critical incident management in the operating room, that might be a one or a two day process. And so you can imagine running a 54,000 CRNAs through that over the course of a couple of years. It would be pretty daunting. The other piece of that is travel. And you know, for our folks that live out in the west of the Mississippi, uh, independent practicing CRNAs, practicing critical access hospitals, folks that practice in, in areas of the country where a simulation center might be day's drive away, there's a potential for lost income, not only lost income, but the cost of having somebody come in and cover for them while they're gone. And the other thing is that there's the specter of what if you go to the Sim Center and you don'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 financial and logistical and practice issues that really have to be resolved before, you know, we would engage in a system of systematic high fidelity patient simulation as a criteria for core recertification. So that technology is young and things are changing constantly. So there may be an opportunity to do virtual reality at some point a remotely they could help satisfy that. But to the analogy with the airline industry, there is no doubt whatsoever that high fidelity simulation in the airline industry has contributed dramatically to traveler's safety. And I would be pretty reluctant to get in an airplane where the, where the pilot or copilot hadn't undergone that kind of rigorous critical event training. So that's something we've got to look at in the long run. You know, there are now pretty convincing of published evidence to support using a cognitive aid in the operating room to help manage crises. So that's another avenue that we want to take a look at, line down the road if, if that has a place in credentialing or with simulation. So it's a wide open landscape. So you know, we've got some work to do to see if there's a place for that.

Mike MacKinnon: 33:16

Oh, excellent answer. The NBCRNA, hasn't really said a whole lot about types of practice models or anything like that or how they feel about them. And as we know, CRNAs working probably three main practice models, one in an anesthesia care team with physician anesthesiologists, often in a medical direction model, one to four style or you know, collaborative practice where everyone's in their own room or there may be just one physician for 20, 30, CRNAs. And then of course an independent practice style where they're working to full scope of practice and, managing the cases day to day and doing every portion of that pre anesthetic to post anesthetic process. One of the questions is how has the NBRNA supported that full scope of practice? Kind of, you know, the CRNAs who are all by themselves or with a CRNA group doing this entire range of things. In terms of recertification, what things have, has the NBCRNA already done or what plans may there be to expand that sort of offering to that group of people?

Dr Terry Wicks: 34:13

Well I think that probably the most prominent piece of evidence to show that support was the creation of the nonsurgical pain management certification course. That's a pretty complex in a high level area of practice, but it's one where particularly CRNAs in the rural area absolutely needed their support. You know, the NBCRNA tries to provide good information to the council on accreditation and to the AANA where appropriate to help them in their advocacy efforts. The NBCRNA specifically kind of takes a, you know, an arms length distance from a lot of the political charged discussions that take place as far as how CRNAs are able to practice or in what areas you're able to practice. Now our main focus is making sure that CRNAs keep their knowledge up to date and that our certification process really meets the highest standards of the contemporary recertification industry. It's always going to be a challenge to remain apolitical for the NBCRNA, but you'll always be that resource for the or for the AANA, to provide the information that we can to support the CRNA practice.

Mike MacKinnon: 35:21

Well part of the reason I ask is because you know, the NBCRNA has this mission to promote patient safety and I, you know, as we are well aware, based on the evidence, all available evidence is CRNAs are safe in any model. It doesn't matter what model you work in. And with this a continuous and constant rapidly expanding full scope of CRNA practice costs across the country, both in autonomous style models and independent models and anesthesia care team, sort of on the wane, what actions has or does the NBCRNA plan to undertake to help support that model? Because obviously, you know, if there's more and more CRNAs in that kind of a model, there's an expansion of the needs of those CRNAs both in recertification and certification and an education. And so with your certification portion, how would you do that best?

Dr Terry Wicks: 36:05

Well, I think we've been asked by a couple of different interested CRNAs to evaluate the possibility of providing a, perhaps in obstetrics certification credential or a regional anesthesia recognition. So we have to look at those things very carefully, recognizing that the possibility exists that by creating that sort of a recognition that it's possible we could even box CRNAs out from those areas of practice. So that's something that we have to look at very, very carefully. But other than that, you know, we really have stayed pretty well clear of the, of the political discord out there in the healthcare industry and really tried to sustain our focus right on there on certification recertification.

Mike MacKinnon: 36:45

So at this point there's nothing, there's nothing particularly specific at the NBCRNA does to support that full scope of practice other than the recertification is broad.

Dr Terry Wicks: 36:53

Right? It's really kind of outside of our wheel house.

Mike MacKinnon: 36:56

Okay. And then probably one of the most controversial things that's happened in our profession recently is the AANAs acceptance of the, of this new title, a nurse anesthesiologist. And so that's given controversial both in a political way, even internally, uh, and outside externally. What is the NBCRNAs position on that and how or what would the NBCRNA be able to do to support that moving forward as it grows in popularity? Assuming it does.

Dr Terry Wicks: 37:24

So what we would have to do, uh, is to really engaged in a, a, in a knowledge based discussion what the NBCRNA wants to do. We have not undertaken that formal discussion at a board level. And so the headline is that we haven't considered that, however, w e're not ignorant of what's going on i n, in the anesthesia community. And you know, recognize that AANA board of directors has allowed CRNA's where permissible to use t he descriptor, a nurse anesthesiologist. And I know that some boards of nursing have recognized that. S o I think what we're waiting for before we really engage in a discussion about that on a policy level or as a posture is to wait until we see where the tide is taking us. U h, I know that there was a bylaws change proposal that was initially intended to be brought forward t oday i n a business meeting that was initially going to ask for a change in the name of the organization. And there seemed to be a lot of division about that. And so that was withdrawn. So we are really taking a couple steps back. We're g oing t o kind of watch where that goes. Obviously i f that gained some momentum, we're going to have to look at what boards of nursing are designing, what state legislators are deciding, u h, in terms of recognition of that title. A nd we'll kind of go from there.

Mike MacKinnon: 38:38

And so what, what would that look like? Does it change the recertification exam title? Does it change the process by the, the certification is there now two certifications, CRNA anesthetist, CRNA anesthesiologist, you know, looking down the road in the future. If this got very popular and you guys decided that as an NBCRNA you had to expand this offering or do this and re-certification, what, what does that look like? Are there two different titles? Is there one combined?

Dr Terry Wicks: 39:05

Well I think what we would have to do is go back to our accrediting body, the National Council on certifying agencies and the accreditation board for nursing specialty accreditation and have a conversation with them and possibly even go as far up the line as the institute for credentialing excellence and see what stipulations that would have to be satisfied if we were, if we embarked on a change. My guess is is that at least initially, and this is just speculation, that there might be a period of time when when both are recognized, but again that I'm guessing is a little ways down the line and obviously we would have to have an intense and a deep dive conversation at a board level about the direction we want it to go.

Mike MacKinnon: 39:46

Excellent. And so we basically come to the end of the interview. Terry, I appreciate you being here. It has been great. A great conversation. As usual. What last things would you leave our audience with about the NBCRNA, the CPC and anything that they should know?

Dr Terry Wicks: 40:02

Sure. I think that's a great question, Mike. Thank you for asking that. Uh, every time I have an opportunity to engage with CRNAs on social media or face to face at meetings or even in individual institution where I happen to have a chance to visit with CRNAs, I asked them to go to the NBCRNA website. There is just an enormous wealth of resources there. There's guidance, there's an avenue there to look at your progress towards recertification and get a graphic representation of what you need to do. Call the office. Uh, our staff is available seven, well not seven days a week. available five days a week. They always answer the phone and if they don't have an answer for you, they'll get one. Reach out to us. We are, we are at state meetings, we're at private CE vendors meetings trying to make our presence and you know, ask us questions, go to the website, get some additional information. And, uh, we really hope that people recognize that we're working on their behalf as well as on the behalf of the patient.

Mike MacKinnon: 41:00

Well, thank you so much, Dr Wicks. I appreciate your time and have a great day.

Dr Terry Wicks: 41:05

Okay, thank you Dr MacKinnon. I appreciate it.

OUTRO: 41:07

That's all for this episode of anesthesia deconstructed. For more information based on today's discussion, be sure to visit us@ anesthesia-deconstructed.com you'll also gain access to our blogs, editorials, and more resources to keep you updated on the science, politics, and realities of today's medical industry. That's anesthesia-deconstructed.com.