ASA Newsletter

[OB1🤙]

I am disturbed by it.

It used to be a somewhat interesting read.

That all changed with the advent of the PSH push.

Now it reads like a thinly-veiled propaganda rag. Seems like every article for the last few months has said "PSH! PSHPSHPSH!! OMGOMG PSH! Everything will be perfect forever because PSH!"

They are bringing the hard sell, and that can only mean one thing- this thing needs to be sold.

I dunno what reeks of desperation more- a whole life insurance salesman, or the ASA trying to get buy-in on this concept.

I mean, I get that they're trying to do *something*. But do they have to sound so... used-car salesman-y while they do it?

---

Members don't see this ad.

 

[deleted171991]

They actually believe in it. Why? Because they want to stay relevant as bosses. If the hospitals wanted us to dig trenches, they would sell us trenches. It's not them who's doing the digging, right?

I am afraid the ASA will end up becoming the AMA of anesthesia.

 

[BuzzPhreed]

The ASA has had the fight whipped out of them. So they're picking someone new to befriend. The surgical home is going to be a colossal failure. More work, more responsibility, and less pay. It is going to sink our profession once and for good.

 

[norwood]

I think we should have the PNH, the perioperative nursing home. You have one nurse who admits you to the hospital, helps you get into your hospital gown, scrubs in and helps the surgeon, recovers you in PACU, and does your followup after you go home. Who cares how inefficient it is? It's a change, so it must be awesome!

 

[IlDestriero]

It's painful. How much of the ASA meeting was devoted to this? I skipped this year.

 

[deleted126335]

-Fighting a defensive war.
-Trying to develop alternative strategies.

Got any specific bright ideas? If so please share.

 

[criticalelement]

Any hard working practicing physician who voluntarily gives money to the ASA for membership needs their head examined. The ASA is the problem,not the solution.

 

[kazuma]

Any hard working practicing physician who voluntarily gives money to the ASA for membership needs their head examined. The ASA is the problem,not the solution.

I understand your frustration, but who do you suggest we support besides the ASAPAC? There are dozens of organizations who are actively trying to kill our specialty. Is the war over?

 

[criticalelement]

There are dozens of organizations who are actively trying to kill our specialty. Is

THE ASA is one of them

 

[Guy Caballero]

I have also grown weary of this PSH tripe. There is a certain speaker who, it seems, has been on the PSH Roadshow, speaking about this at every major meeting. I am not sold on it yet and tune it out when I see articles or hear lectures on it. It is like white noise.
I don't know what the answer is for our specialty, but I don't think PSH is it.

 

[deleted171991]

I have also grown weary of this PSH tripe. There is a certain speaker who, it seems, has been on the PSH Roadshow, speaking about this at every major meeting. I am not sold on it yet and tune it out when I see articles or hear lectures on it. Tis like white noise.
I don't know what the answer is for our specialty, but I don't think PSH is it.

PSH is definitely not for everybody. I can see many anesthesiologists (especially non-IM- or non-CCM-trained ones) being very unhappy about having to deal with periop problems, and "owning" patients pre- or postop.

They seem to be trying to import some kind of a European model, but European anesthesiologists are all CCM-trained.

 

[IlDestriero]

We will just set up guidelines and defer the patients to NPs or CRNAs while "supervising" the clinic from the lounge. Maybe have residents too, as we need to train them on the new PSH concept.

 

[kazuma]

I can see why a CCM trained doc would be useful in the PSH for patients in the unit. But it seems like any anesthesiologist could fulfill the PSH role for outpatients and floor patients assuming they want to take on that responsibility. But as you mentioned they might not be happy in this role. One of my senior attendings who staffs the pre-op clinic kind of scoffed when I mentioned that my CCM fellowship might be useful if we adopt the PSH. He thinks the pre-op folks are the wave of the future and I think he would been elated had I done a pre-anesthesia clinic fellowship instead of CCM.

 

[deleted171991]

I can see why a CCM trained doc would be useful in the PSH for patients in the unit. But it seems like any anesthesiologist could fulfill the PSH role for outpatients and floor patients assuming they want to take on that responsibility.

I wouldn't be so sure. Many anesthesiologists have pretty poor IM knowledge, besides what's needed in the OR. Some places that are experimenting with the PSH are using CCM guys. Also academic departments seem to love the idea of extending their influence in the hospital, including hiring more CCM guys for verious purposes, and taking over more ICUs.

But as you mentioned they might not be happy in this role. One of my senior attendings who staffs the pre-op clinic kind of scoffed when I mentioned that my CCM fellowship might be useful if we adopt the PSH. He thinks the pre-op folks are the wave of the future and I think he would been elated had I done a pre-anesthesia clinic fellowship instead of CCM.

Pre-anesthesia clinic fellowship? Don't you need an ortho fellowship before that?

 

[Noyac]

Any anesthesiologist should be able to staff a PSH.

However, hospitalists can do it as well. And they are cheaper. Plus it's probably an easier day for them than the floor scut.

 

[deleted171991]

Any anesthesiologist should be able to staff a PSH.

The academic ones that trained me probably wouldn't. A PSH is far more than just a preop clinic or postop pain management. We'll see the answer in time.

 

[koan]

PSH has been a topic on the interview trail as well. Tis funny to hear chairmen and PDs give a vague endorsement to the concept not knowing how it may or may not be implemented into their department.

 

[Noyac]

The academic ones that trained me probably wouldn't. A PSH is far more than just a preop clinic or postop pain management. We'll see the answer in time.

How in the world would they not be able to do this?

 

[dhb]

European anesthesiologists are all CCM-trained.

Not true

 

[deleted171991]

What countries are the exception? I am truly curious.

 

[Spinach Dip]

Hey, what's that sound?

Do you hear that?

...

I think it's the sound of a couple thousand med students laughing at this specialty and its inability to defend its future or maintain a coherent line of thought. (Has someone been sniffing the sevo?)



Perhaps the attendings on this board haven't thought of it this way, so let me ramble a bit....

When students are looking at which specialty to apply to in their third year, 2 of the most important things are "Do I enjoy working in this specialty?" and "Can I do this for the next several decades?" (Okay, so maybe not all consider those 2 questions, but those who ignore them tend to regret their decisions...)

Right now, anesthesia shows no future to me. All I hear is complaining from every side and a terrifying lack of impetus to DO anything.

And then the ASA decides to take a stand and advocate for the further degradation of this specialty. So we are going to join pre-op nurses, anesthesiologists, and post-op hospitalists into a single person and somehow we will improve care and decrease spending? I'm sorry, but I'm not buying the smoke and mirrors. (And I would like to know who's been sniffing the sevo.)



This is what I see for anesthesia in the future: the specialty will continue to degenerate as CRNAs, PSHs, etc, all try to cut themselves a slice of the pie while the ASA twiddles its thumbs and all its board-certified members b1tch and whine, but do nothing. Less highly-qualified med students will apply to the specialty until the STEP scores of its applicants reach the lowest specialties (pediatrics, psychiatry, and fam med). The term "ROAD specialty" will become "ROD specialty".

Eventually things will reach a crisis point. There will be a call for more physician oversight of CRNAs. But how many decades and patient deaths are between here and there is beyond me.



In other words: keep up the good work and reap what you sow!



/rant

 

[urge]

I wouldn't be so sure. Many anesthesiologists have pretty poor IM knowledge, besides what's needed in the OR. Some places that are experimenting with the PSH are using CCM guys. Also academic departments seem to love the idea of extending their influence in the hospital, including hiring more CCM guys for verious purposes,
and taking

What is there to manage? Htn, DM, pain, constipation, afib, and ischemia.

Do you need a CCM felllowship for that? I don't think so.

 

[kazuma]

What is there to manage? Htn, DM, pain, constipation, afib, and ischemia.

Do you need a CCM felllowship for that? I don't think so.

Umm nutrition, hello! Tube feeds at goal and such. We learn how to consult nutritionists throughout ccm fellowship.

 

[Noyac]

Hey, what's that sound?

Do you hear that?

...

I think it's the sound of a couple thousand med students laughing at this specialty and its inability to defend its future or maintain a coherent line of thought. (Has someone been sniffing the sevo?)



Perhaps the attendings on this board haven't thought of it this way, so let me ramble a bit....

When students are looking at which specialty to apply to in their third year, 2 of the most important things are "Do I enjoy working in this specialty?" and "Can I do this for the next several decades?" (Okay, so maybe not all consider those 2 questions, but those who ignore them tend to regret their decisions...)

Right now, anesthesia shows no future to me. All I hear is complaining from every side and a terrifying lack of impetus to DO anything.

And then the ASA decides to take a stand and advocate for the further degradation of this specialty. So we are going to join pre-op nurses, anesthesiologists, and post-op hospitalists into a single person and somehow we will improve care and decrease spending? I'm sorry, but I'm not buying the smoke and mirrors. (And I would like to know who's been sniffing the sevo.)



This is what I see for anesthesia in the future: the specialty will continue to degenerate as CRNAs, PSHs, etc, all try to cut themselves a slice of the pie while the ASA twiddles its thumbs and all its board-certified members b1tch and whine, but do nothing. Less highly-qualified med students will apply to the specialty until the STEP scores of its applicants reach the lowest specialties (pediatrics, psychiatry, and fam med). The term "ROAD specialty" will become "ROD specialty".

Eventually things will reach a crisis point. There will be a call for more physician oversight of CRNAs. But how many decades and patient deaths are between here and there is beyond me.



In other words: keep up the good work and reap what you sow!



/rant

Have you seen how fast some of the other specialties are losing ground?

 

[Carbocation1]

Have you seen how fast some of the other specialties are losing ground?

Can you provide examples?

 

[Spinach Dip]

Have you seen how fast some of the other specialties are losing ground?

Perhaps anesthesia is the most obvious?

 

[kazuma]

Can you provide examples?

Emergency Medicine- I worked with PA's and NP's during half of these rotations as am intern and MS3.

FP/IM- again, tons of independent practitioners. I remember Oregon had a bill that would allow them to be reimbursed at the same rate as a physician. I didn't follow up to see if it passed, but expect to see more of this as the ACA unfolds.

OB/Gyn- several of my wife's friends refuse to have their kids delivered by a physician and insist on midwives. My own mom sees an independent NP for gyn because its too difficult to get an appt with a real doctor.

Ophthalmology- I'm not up to speed in the details, but I know some states are allowing optometrists to do certain procedures.


PICU/NICU's- NP city at our shop, they literally run the place and tell the few docs up there what to do. They are always called for complicated deliveries or when the infant is expected to have issues. My attending walked in after a triplet delivery to see 3 blue babies 10min after birth, no NICU attending present. She introduced herself as an anesthesiologist and asked if they could use some help with the intubations because the were clearly not successful at that point. They snapped at her and said "we are flight nurses, we know how to intubate!" I've had them bring a preemie with agonal breathing back to be with mom with the explanation, "sorry the child is passing away, we can't get a breathing tune in, there is nothing we can do, don't worry the child is comfortable."

Surgery seems somewhat protected now, but I've seen PA's do entire neurosurgery cases and almost all of a CABG in private practice. The surgeon is usually in the lounge and just gets called in for the "critical portions" and may or may not scub in. The PA's/NP's did all of the floor consults at this private hospital. PA's routinely place EVD's unsupervised in our academic center. I've delt with the consequences of one that was placed incorrectly. ICP 10, PA wants to turn off sedation to do neuro exam even though BP>200, HR<50. I told him no, and I didn't believe the EVD was in the right place and he needed to advance it. As soon as he did ICP>70, I called the surgeons who booked a Stat crani and I wheeled the patient down to the OR myself to save time. It was too late through, he herniated and was declared brain dead the next day.


Expect to see more mid level encroachment and stories like these. Patients don't know what goes on behind the scenes. They usually just want a "provider" who's friendly and available. The current administration strongly believes mid levels are the answer to our healthcare "crisis." Just read the ACA.

 

[IlDestriero]

If I saw any of that Kaz, I'd be prepping the house for sale and calling around for leads on a new gig.

 

[Carbocation1]

Emergency Medicine- I worked with PA's and NP's during half of these rotations as am intern and MS3.

FP/IM- again, tons of independent practitioners. I remember Oregon had a bill that would allow them to be reimbursed at the same rate as a physician. I didn't follow up to see if it passed, but expect to see more of this as the ACA unfolds.

OB/Gyn- several of my wife's friends refuse to have their kids delivered by a physician and insist on midwives. My own mom sees an independent NP for gyn because its too difficult to get an appt with a real doctor.

Ophthalmology- I'm not up to speed in the details, but I know some states are allowing optometrists to do certain procedures.


PICU/NICU's- NP city at our shop, they literally run the place and tell the few docs up there what to do. They are always called for complicated deliveries or when the infant is expected to have issues. My attending walked in after a triplet delivery to see 3 blue babies 10min after birth, no NICU attending present. She introduced herself as an anesthesiologist and asked if they could use some help with the intubations because the were clearly not successful at that point. They snapped at her and said "we are flight nurses, we know how to intubate!" I've had them bring a preemie with agonal breathing back to be with mom with the explanation, "sorry the child is passing away, we can't get a breathing tune in, there is nothing we can do, don't worry the child is comfortable."

Surgery seems somewhat protected now, but I've seen PA's do entire neurosurgery cases and almost all of a CABG in private practice. The surgeon is usually in the lounge and just gets called in for the "critical portions" and may or may not scub in. The PA's/NP's did all of the floor consults at this private hospital. PA's routinely place EVD's unsupervised in our academic center. I've delt with the consequences of one that was placed incorrectly. ICP 10, PA wants to turn off sedation to do neuro exam even though BP>200, HR<50. I told him no, and I didn't believe the EVD was in the right place and he needed to advance it. As soon as he did ICP>70, I called the surgeons who booked a Stat crani and I wheeled the patient down to the OR myself to save time. It was too late through, he herniated and was declared brain dead the next day.


Expect to see more mid level encroachment and stories like these. Patients don't know what goes on behind the scenes. They usually just want a "provider" who's friendly and available. The current administration strongly believes mid levels are the answer to our healthcare "crisis." Just read the ACA.

!!!

 

[kazuma]

If I saw any of that Kaz, I'd be prepping the house for sale and calling around for leads on a new gig.

I wouldn't blame you. It seems like a major liability even if you're not directly involved are actually supervising the resident next door in the C-section. "But doctor, you're a physician and anexpert in airway management, why didn't you take over?"

Another nice "service" they provide is elective intubations on NICU babies that are coming down to the OR for a procedure. I’ll look the patient up the night before- spontaneous breathing on room air. Then I’ll look them up throughout the day during earlier cases and suddenly they’re tubed and on a vent. They think they have the patent on infant intubations. It pisses my attendings and I off and we threaten to cancel cases and they’ll quit doing for a while. But it isn’t long until the cycle continues. They don’t care about the increase risk of morbidity from transporting a vented preemie down six floors to the OR.

 

[IlDestriero]

That elective intubation nonsense would stop with a chief to chief discussion and a policy. Either that or ask them to transport to and from the OR. They only kids that get electively intubated at my shop are ones that are circling the drain anyway. There's no need for another day of stress, struggling with CPAP, etc when they're going to the OR in 12-24 hours with no plans to extubate.

 

[Spinach Dip]

My attending walked in after a triplet delivery to see 3 blue babies 10min after birth, no NICU attending present. She introduced herself as an anesthesiologist and asked if they could use some help with the intubations because the were clearly not successful at that point. They snapped at her and said "we are flight nurses, we know how to intubate!"

"We know how to intubate!" Not, for example, "Thanks for the offer, but we got this under control." or maybe, "You take the little one while we focus on these two."



This is the kind of bullsh1t the ASA needs to be focusing on. Show to the public (or lawmakers, or both) that CRNAs ≠ Anesthesiologists and RNs ≠ MDs. Go on the offensive.

But instead the ASA seems content to do nothing for years. Then jump on the PSH bandwagon like a bunch of teenage girls on a poster of Justin Beiber.

 

[Gern Blansten]

I've had them bring a preemie with agonal breathing back to be with mom with the explanation, "sorry the child is passing away, we can't get a breathing tune in, there is nothing we can do, don't worry the child is comfortable."

Bizarre...surprised the medical board has not intervened on that type of thing. They just gave up??!!

 

[kazuma]

Bizarre...surprised the medical board has not intervened on that type of thing. They just gave up??!!

Yeah, I couldn't believe it and it seemed like they gave up rather quickly. They certainly didn't ask my attedning or I for help and that was their explanation. "Sorry baby is too small we couldn't get a breathing tube in." I don't recall the weight, but I've taken similar size/age kids to the OR for surgery before. It was a 25 or 26 week old, so the prognosis wasn't great to begin with. It was sad to be sitting next to mom as she watched her baby gasp for air and eventually die while the OB was closing. Aren't nurses immune from medical board intervention since they are under the nursing board?

 

[nimbus]

Yeah, I couldn't believe it and it seemed like they gave up rather quickly. They certainly didn't ask my attedning or I for help and that was their explanation. "Sorry baby is too small we couldn't get a breathing tube in." I don't recall the weight, but I've taken similar size/age kids to the OR for surgery before. It was a 25 or 26 week old, so the prognosis wasn't great to begin with. It was sad to be sitting next to mom as she watched her baby gasp for air and eventually die while the OB was closing. Aren't nurses immune from medical board intervention since they are under the nursing board?

A little off topic but there is a good chance they did that baby and that family a huge favor. I'm not a neonatologist for a reason. I wouldn't want my own 25 week newborn to be intubated.

 

[OB1🤙]

Scary stuff above.

So I think the PSH push is, obviously, an attempt to define our (MD) services as being value-added. This may work as they want it to in certain academic environments, but out here in the real world it's DOA.

I think it IS important to be "value-added." But I don't think the way to prove that is just to assume all the scut.

Let's look at preop and postop.

Here's the thing about preop- LAW13: THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.

The value physicians bring to the preop process is to reduce the useless tests and visits that are ordered. I think most patients would benefit from a cursory glance at the chart by an anesthesiologist, to make sure there are no MAJOR red flags, but really, preop workups should generally be pretty minimal. Whoever is in charge of their HTN and DM should optimize those things, not us. Since we shouldn't routinely be getting cxr/EKG/panlabs for most cases anyway, why do we think all of a sudden we can add huge value preop?

Postop, I see value in a robust pain service. For hearts and big cases, I see value in an echo-enabled consultant service, either as the primary CCM service or to supplement a non-anesthesiologist CCM service.

I don't see a shred of value whatsoever in becoming an intern all over again and dealing with blood sugars at 3AM.

I think this is a last-ditch effort against bundled care that just reeks of desperation. I think the solutions to these issues will be local. Practices will either step up and provide added value as appropriate for their particular situation and thrive, or they won't and will go extinct.

But the PSH? Naw, man. That's not the answer. Not in the real world.

 

[Planktonmd]

They actually believe in it. Why? Because they want to stay relevant as bosses. If the hospitals wanted us to dig trenches, they would sell us trenches. It's not them who's doing the digging, right?

I am afraid the ASA will end up becoming the AMA of anesthesia.

That transformation has already happened