Anesthesiologist Assistants, SRNA training, support of the AAAA

[PieOHmy]

1. My friend took a job as a cardiac anesthesiologist at a place with a heavy crna presence and he told me that it is the expectation that he teach SRNAs to put in central lines and go over the TEE findings with him.

This is emblematic of the future

2. All the young anesthesiologists should support the AAAA (Anesthesiologist Assistants) and Physician Assistants in anesthesia. That is what needs to happen.

If the surgeons can have PAs doing surgery, we should be allowed to train PAs to deliver anesthesia under our direction.

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[IMGASMD]

It’s their future employer that will determine what they’re allow to do..... one of the hospitals allow crna to do spinal/epidural. One will not let CRNA touch the back. There are some practices that will have CRNA in cardiac rooms. Some only cardiac trained MD that can do cardiac cases.

We as a profession should regulate and take responsibility. But that’s harder to do than say we only hire AAs. That being said, I will still be looking for a MD only gig for my next job.....

 

[Status Sciaticus]

Why not just refuse to train SRNAs/CRNAs... just have it built into your contract.

 

[Justice4all]

The younger generation needs to stop this now !. Older guards chase the almighty dollar now they have lost control.

 

[AdmiralChz]

If you look historically, PAs have had no interest in anesthesia AT ALL. None. When they were approached back decades ago when they were still getting the movement started they walked away. Today, to my knowledge no state allows for PAs to administer anesthesia. This is how the AA movement was born.

I whole-heartedly agree about AAs and our state societies should not allow balanced billing and insurance expansion to distract from this goal.

 

[AdmiralChz]

Why not just refuse to train SRNAs/CRNAs... just have it built into your contract.

Often this is not feasible or advisable - especially if your hospital is linked with an academic training program. Our hospital flatly refuses to give out any contracts that turn down PA/NP/SRNA students straight up. At some point you have to keep the peace with the big dog in town and just because your group refuses doesn’t mean the whole profession will fall like a house of cards. Such training programs, to the positive, are good recruiting grounds as well.

All that being said, we have set limits on what SRNAs are able to do. The hospital could care less about the details of our training as long as we check that box. A-lines and simple spinals ONLY. No blocks, CVLs, epidurals, awake intubations, unsupervised work, etc. Our home SRNAs go to some rural hospital to get block experience and travel halfway across the country for a month to get CVL experience in Columbus, Ohio. We were starting to consider adding an OB rotation but we unanimously voted against it when the “we are the answer” campaign came out. No clue where they get that training as they have been kicked out of multiple sites.

 

[deleted126335]

Contracts are less the issue than culture. At the end of the day we do have absolute authority of the anesthetic plan when we are supervising. Exercising that authority contrary to local culture sometimes has consequences.

 

[stinkycheese]

I don’t teach the SRNAs who work with me A DAMN THING. If they think they can be independent of us then they can learn from their peers (other RNs) not from me. Once one of them called me an MDA and I shut that crap down right quick. You think you’re my equal? Train your own goddamn trainees then, dingus.

 

[deleted171991]

Why not just refuse to train SRNAs/CRNAs... just have it built into your contract.

Because there is such a "shortage" of anesthesiologists that almost nobody negotiates contracts with you. It's their way or the highway.

 

[deleted171991]

Often this is not feasible or advisable - especially if your hospital is linked with an academic training program. Our hospital flatly refuses to give out any contracts that turn down PA/NP/SRNA students straight up. At some point you have to keep the peace with the big dog in town and just because your group refuses doesn’t mean the whole profession will fall like a house of cards. Such training programs, to the positive, are good recruiting grounds as well.

All that being said, we have set limits on what SRNAs are able to do. The hospital could care less about the details of our training as long as we check that box. A-lines and simple spinals ONLY. No blocks, CVLs, epidurals, awake intubations, unsupervised work, etc. Our home SRNAs go to some rural hospital to get block experience and travel halfway across the country for a month to get CVL experience in Columbus, Ohio. We were starting to consider adding an OB rotation but we unanimously voted against it when the “we are the answer” campaign came out. No clue where they get that training as they have been kicked out of multiple sites.

Or they just go to a VA that uses the ACT model.

 

[deleted171991]

The younger generation needs to stop this now !. Older guards chase the almighty dollar now they have lost control.

Read my lips: That. Ship. Has. Sailed.

 

[Silo004]

Often this is not feasible or advisable - especially if your hospital is linked with an academic training program. Our hospital flatly refuses to give out any contracts that turn down PA/NP/SRNA students straight up. At some point you have to keep the peace with the big dog in town and just because your group refuses doesn’t mean the whole profession will fall like a house of cards. Such training programs, to the positive, are good recruiting grounds as well.

Man ... As a resident, who will graduate in ~ 20 mos I hope I can show a bit more solidarity with the profession.

 

[AdmiralChz]

Man ... As a resident, who will graduate in ~ 20 mos I hope I can show a bit more solidarity with the profession.

Ok Dr. Resident with a lot of real life experience. How should I and others change our approach? Tell the hospital to F off? Tell the medical school with a SRNA program to go screw themselves?

That’s not how you keep administrators happy. If they bid out the contract we will lose to some terrible AMC Where the job will pay crap and work the crap out of you. For better or worse, they - the suits - are the number one people to keep happy in medicine.

there are places out there (A lot of them) that allow SRNAs to be alone in the room like a resident with minimal supervision. That’s a dangerous proposition and we expressly do not allow for that - we are a patient-centric, physician-led group and we mame they expressly cleat when we hire new anesthetists. The moment we get some lip back, it’s a warning and then they’re gone.

 

[nimbus]

The moment we get some lip back, it’s a warning and then they’re gone.

How many have been fired? Were there any consequences for the group?

 

[Silo004]

Ok Dr. Resident with a lot of real life experience. How should I and others change our approach? Tell the hospital to F off? Tell the medical school with a SRNA program to go screw themselves?

That’s not how you keep administrators happy. If they bid out the contract we will lose to some terrible AMC Where the job will pay crap and work the crap out of you. For better or worse, they - the suits - are the number one people to keep happy in medicine.

there are places out there (A lot of them) that allow SRNAs to be alone in the room like a resident with minimal supervision. That’s a dangerous proposition and we expressly do not allow for that - we are a patient-centric, physician-led group and we mame they expressly cleat when we hire new anesthetists. The moment we get some lip back, it’s a warning and then they’re gone.

Oh I wasn't trying to pick a fight. Or be at all critical. The decision makes complete sense to me. Just saying that sounds like a bummer to me. Sucks to be put in that situation

The ASA just came out against the SRNA thing and glad you all are standing tall.

 

[stinkycheese]

But seriously people WHY are we, as MDs, offering training to people who as soon as they're done with training think they are better than/equal to us? If they were truly our equals why can't they train exclusively with CRNAs in opt-out states? Oh right, because CRNAs lack the subspecialty training, medical training, and privileges to have completely RN-run training programs that actually proffer a wide breadth of experience (to say nothing of their depth of knowledge.) As physician extenders having CRNAs sit stools in the OR works fine, but screw those dinguses if they think I am going to teach them anything beyond how to sit a stool (including blocks, lines, neuraxial, or TEE.) F*ck 'em.

 

[AdmiralChz]

How many have been fired? Were there any consequences for the group?

I’ve been here a year and we’ve fired one (we allowed her to resign) who had been with us for 20+ years and another is on very thin ice. Just like with any organization you can’t be a dictatorship and just fire people all over or you’ll have severe employee unrest. That being said, we have to protect our patients and they understand that.

Oh I wasn't trying to pick a fight. Or be at all critical. The decision makes complete sense to me. Just saying that sounds like a bummer to me. Sucks to be put in that situation

Absolutely, I can suck. We do the best we can, it couod. Reality is often disappointing.

As physician extenders having CRNAs sit stools in the OR works fine, but screw those dinguses if they think I am going to teach them anything beyond how to sit a stool (including blocks, lines, neuraxial, or TEE.)

Yep that’s our rotation. Training anesthesia technicians, basically.

 

[ProRealDoc]

1. My friend took a job as a cardiac anesthesiologist at a place with a heavy crna presence and he told me that it is the expectation that he teach SRNAs to put in central lines and go over the TEE findings with him.

This is emblematic of the future

2. All the young anesthesiologists should support the AAAA (Anesthesiologist Assistants) and Physician Assistants in anesthesia. That is what needs to happen.

If the surgeons can have PAs doing surgery, we should be allowed to train PAs to deliver anesthesia under our direction.

I'd suggest your friend quit his job and go elsewhere.

 

[deleted171991]

I'd suggest your friend quit his job and go elsewhere.

This is standard at my workplace too.

And, yes, it's just another nurse-run hospital, where physicians are expected to put everybody through medical school on the job. "Top of the license".

 

[Status Sciaticus]

Often this is not feasible or advisable - especially if your hospital is linked with an academic training program. Our hospital flatly refuses to give out any contracts that turn down PA/NP/SRNA students straight up. At some point you have to keep the peace with the big dog in town and just because your group refuses doesn’t mean the whole profession will fall like a house of cards. Such training programs, to the positive, are good recruiting grounds as well.

All that being said, we have set limits on what SRNAs are able to do. The hospital could care less about the details of our training as long as we check that box. A-lines and simple spinals ONLY. No blocks, CVLs, epidurals, awake intubations, unsupervised work, etc. Our home SRNAs go to some rural hospital to get block experience and travel halfway across the country for a month to get CVL experience in Columbus, Ohio. We were starting to consider adding an OB rotation but we unanimously voted against it when the “we are the answer” campaign came out. No clue where they get that training as they have been kicked out of multiple sites.

If all you have to do is check the box, why allow them to do spinals or A-lines? Why not just teach them the basics and keep it to that? Not arguing, just honestly curious. Would it not help to have some of your colleagues from your group on these executive committees to help gain some clout?

I don’t teach the SRNAs who work with me A DAMN THING. If they think they can be independent of us then they can learn from their peers (other RNs) not from me. Once one of them called me an MDA and I shut that crap down right quick. You think you’re my equal? Train your own goddamn trainees then, dingus.

This is viewpoint I hope other anesthesiologists will adopt.

 

[Mman]

I teach SRNAs how to be a part of a team approach to care. Ours perform no TEEs, CVPs, PNBs, or advanced airway techniques. They do place ETTs, IVs, art lines, and spinals.

 

[deleted171991]

I teach SRNAs how to be a part of a team approach to care. Ours perform no TEEs, CVPs, PNBs, or advanced airway techniques. They do place ETTs, IVs, art lines, and spinals.

Same here. But the CRNAs teach them how to be independent, I'm not naive about that.

 

[Mman]

Same here. But the CRNAs teach them how to be independent, I'm not naive about that.

they don't teach them how to be independent but they think they do. They do not have the training to be independent no matter how much some of them scream it til they are blue in the face.

 

[deleted171991]

they don't teach them how to be independent but they think they do. They do not have the training to be independent no matter how much some of them scream it til they are blue in the face.

Some of the CRNAs I work with have worked "independently" for years before, meaning that their physicians did/could not respect TEFRA. So they would disagree with you.

 

[Mman]

Some of the CRNAs I work with have worked "independently" for years before, meaning that their physicians did/could not respect TEFRA. So they would disagree with you.

I am well aware. I am saying they are not trained to do so safely no matter what they tell you.

 

[AdmiralChz]

If all you have to do is check the box, why allow them to do spinals or A-lines? Why not just teach them the basics and keep it to that? Not arguing, just honestly curious. Would it not help to have some of your colleagues from your group on these executive committees to help gain some clout?

It mirrors how our practice is run, since we hire many of the SRNAs I’d rather them learn this skill as a student than a CRNA. Only other thing would be Labor epidurals but we aren’t interested in the high wet tap rate seen with trainees and our anesthetists and docs are too busy on L&D to do much teaching.

 

[jthedestroyr]

It’s their future employer that will determine what they’re allow to do..... one of the hospitals allow crna to do spinal/epidural. One will not let CRNA touch the back. There are some practices that will have CRNA in cardiac rooms. Some only cardiac trained MD that can do cardiac cases.

We as a profession should regulate and take responsibility. But that’s harder to do than say we only hire AAs. That being said, I will still be looking for a MD only gig for my next job.....

Why not just refuse to train SRNAs/CRNAs... just have it built into your contract.

As a recent grad and current fellow that has interviewed for both private practice and academic jobs, I can tell you good luck. Private practice places will tell you, this is the contract, sign it or walk (academics more or less the same).

A friend told me while on the interview trail, they thought they found a great job, but then was told this gem. "while you were running 2-3 rooms, you still might be "staffing" epidurals with a CRNA upstairs[since you're too busy to start 3-4 rooms and do the epidural]". This place also had an SRNA school.

Therefore CRNA placing the epidurals with SRNA on guess whose license, you guessed it, YOURS. I told my buddy to run from this job, as the group I'm interested doesn't train SRNA, nor even lets their CRNAs place epidurals. Is that a pain in the middle of the night, yes, but as physicians there are certain things we just have to stomach and stuck it up, otherwise we will keep losing ground. It's a slippery slope, that once you let them do XYZ, its easy to transition into ABC.

That's the problem with Anesthesia, allowing more and more autonomy to keep the CRNA happy. The amazing location cities, have these predatory practices, since they know people will be so drawn by the location. Fortunately, there still are amazing groups out there, that don't tolerate this, don't teach SRNA, but you're going to have to be willing to live in a less desirable location. I can tell you these groups exist, and we have members on these boards that belong to those groups.

 

[Status Sciaticus]

As a recent grad and current fellow that has interviewed for both private practice and academic jobs, I can tell you good luck. Private practice places will tell you, this is the contract, sign it or walk (academics more or less the same).

A friend told me while on the interview trail, they thought they found a great job, but then was told this gem. "while you were running 2-3 rooms, you still might be "staffing" epidurals with a CRNA upstairs[since you're too busy to start 3-4 rooms and do the epidural]". This place also had an SRNA school.

Therefore CRNA placing the epidurals with SRNA on guess whose license, you guessed it, YOURS. I told my buddy to run from this job, as the group I'm interested doesn't train SRNA, nor even lets their CRNAs place epidurals. Is that a pain in the middle of the night, yes, but as physicians there are certain things we just have to stomach and stuck it up, otherwise we will keep losing ground. It's a slippery slope, that once you let them do XYZ, its easy to transition into ABC.

That's the problem with Anesthesia, allowing more and more autonomy to keep the CRNA happy. The amazing location cities, have these predatory practices, since they know people will be so drawn by the location. Fortunately, there still are amazing groups out there, that don't tolerate this, don't teach SRNA, but you're going to have to be willing to live in a less desirable location. I can tell you these groups exist, and we have members on these boards that belong to those groups.

QFT. Yeah, Im not looking to go to a place that trains SRNAs if I can help it. Unfortunately, the two states I am interested in (TX and WA) may not have those practices left by the time I graduate :/

 

[jthedestroyr]

QFT. Yeah, Im not looking to go to a place that trains SRNAs if I can help it. Unfortunately, the two states I am interested in (TX and WA) may not have those practices left by the time I graduate :/

Texas is an AMC wasteland from my search (good luck in Houston, its all USAP, Dallas is NAPA or predatory groups, austin i think is NAPA or USAP). WA I know of one group hiring that's MD only, but small city (20-30k and on a coastal area).

 

[qwerty89]

If you are forced to teach use the ol' med school professor tricks.

1) First time you work with a given SRNA ask them if they have read a particular article (pick one) about the procedure (i.e. indications for the procedure). After you get the inevitable "no" say that you can't do the procedure until they know all the indications and contraindications of the procedure.

2) When paired with the student again you need to pimp them about the article. Bonus points if its a random fact that nobody would memorize. Then when they get it wrong you tell them they need to read the article again. Even more bonus points if you say that this is unprofessional and that you will discuss this with their director.

3) When you are finally forced to let them attempt the procedure you need to immediately take over if they so much as pick up the needle incorrectly. Complete the procedure on your own while telling then what a huge disappointment they are.

Over time you will get the reputation of being a hard a** and every SRNA student will actively avoid you.

 

[slabb]

QFT. Yeah, Im not looking to go to a place that trains SRNAs if I can help it. Unfortunately, the two states I am interested in (TX and WA) may not have those practices left by the time I graduate :/

Most of the private practices in the western Washington metro areas are MD only or MD mostly. Matrix, Pacific, Tacoma Anesthesia Associates (AA), Bellingham AA, and Olympia AA are all essentially MD only unless something has changed recently. The notable exceptions are USAP-WA at Swedish, which has been transitioning more to a team model since they sold, Prov Everett/Somnia has been a collaborative MD & CRNA independent practice model for years, Valley Anesthesia Associates which is a mix team model and MDs, and Harrison (Bremerton/Silverdale) has a mix of MD/CRNA collaborative model and physician employment out in Kitsap. Columbia Anesthesia Group in the Vancouver/Portland area has CRNAs, but I don't know how they utilize them. I know very little about any of the practices in eastern Washington.

 

[AdmiralChz]

My friends in Seattle tell me Swedish (USAP) and Valley are moving towards full team model with a rumor of collaborative practice. But salaries are expected to increase substantially. Don’t have any more intel than that, and it’s like 3rd or 4th hand info...

 

[Maverikk]

Do MD only: more respect, more control and you become better at the balance of safe/fast/efficient especially if you're a new grad from an academic place. Only downside is less pay/hr than supervising 4 CRNAs. I had co-residents who went right into supervising 4:1 with experienced CRNAs, it was a rough ride for them. Doing MD only will make you an OR ninja if you work at a busy place.