ASA Perioperative Surgical Home

[DreamLover]

The future and survival of anesthesiology depends on this as the opening session at ASA really ground in this morning-and I agree. Anyone out there actively implementing the PSH?

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[BuzzPhreed]

For the love of all that is good, not this again.

Read this thread.

http://forums.studentdoctor.net/threads/the-surgical-home.1076758/

 

[GA8314]

I used to be a skeptic. But I am no longer. It will be baby steps but I am seeing more and more momentum. I also feel that with the right data (I.e. when does the hospital make money on testing versus losing money on testing etc.) and the right dialogue with administration a small or medium sized group can indeed implement a small program. It will take work and figuring out compensation will take time but I think this is a worthwhile challenge.

We are brainstorming way of starting a pilot program.

 

[secants]

I've read articles about it and this month's ASA anesthesiology print newsletter was dedicated to it but other than lip service, I've yet to see it implemented or anyone interested enough in trying it out.

 

[kazuma]

I've read articles about it and this month's ASA anesthesiology print newsletter was dedicated to it but other than lip service, I've yet to see it implemented or anyone interested enough in trying it out.

UC Irvine has a pilot PSH program in place.

 

[BuzzPhreed]

Yes, exactly. That's the only place this kind of nonsense will flourish: academia.

 

[Sirach38]

Does this stuff mean anesthesiologist of the future are going to be doing all the paperwork, endless rounding, and social work that internists do today? Basically anesthesiologists becoming the PCP for every surgical patient for 30 days? If so, this is absolute garbage. Nobody going into anesthesiology has the desire to be a PCP, baby sit surgical patients, and deal with all of the nightmare social issues that come with it. I would rather work for 80K in the OR than become an internist. One of the main reasons that I'm staying away from surgery is that I HATE all the clinic and rounding that they have to do. If I'm going to be be forced into doing clinic for surgeons, I'd rather do pain clinic or sleep medicine clinic for my own patients.

 

[BuzzPhreed]

Not only that, it is not even remotely the focus of our past or current training.

It is garbage.

 

[kazuma]

Does this stuff mean anesthesiologist of the future are going to be doing all the paperwork, endless rounding, and social work that internists do today? Basically anesthesiologists becoming the PCP for every surgical patient for 30 days? If so, this is absolute garbage. Nobody going into anesthesiology has the desire to be a PCP, baby sit surgical patients, and deal with all of the nightmare social issues that come with it. I would rather work for 80K in the OR than become an internist. One of the main reasons that I'm staying away from surgery is that I HATE all the clinic and rounding that they have to do. If I'm going to be be forced into doing clinic for surgeons, I'd rather do pain clinic or sleep medicine clinic for my own patients.

No not from my understanding, they envision some anesthesiologists optimizing, overseeing and coordinating the care of the surgical patient throughout the peri operative period. The majority of anesthesiologists will continue to work in the OR as they do today. Yes, it's a new idea and dramatic shift from current practices but I haven't heard of any other reasonable solutions as to how anesthesiologists are to remain relevant with the advent of ACO's and bundled payments etc. Whether we like it or not, the way we practice medicine and are reimbursed in the future is changing. That part is out of our control, we can either evolve and adapt to the new environment or let somebody else fill the niche while we allow the specialty to become marginalized.

 

[urge]

Can someone explain what is meant by Periop Surgical Home? Whenever I look it up I find some verbose answers that really don't explain what it is.

PSH strives to achieve the triple aim of better health, better health care, and reduced expenditures through continuous improvement for all patients undergoing surgical procedures. The PSH is a patient-centered, physician-led, multidisciplinary, and team-based system of coordinated care. It guides the patient through the entire surgical experience from decision for the need for surgery until 30 days post discharge from a medical facility. The goal is to create a better patient experience and make surgical care safer; thus, promoting a better medical outcome at a lower cost.

 

[kazuma]

Can someone explain what is meant by Periop Surgical Home? Whenever I look it up I find some verbose answers that really don't explain what it is.

My understanding is that the PSH is the system that coordinates the care for a surgical patient from the time a surgeon determines a surgery is indicated through ~30 days post op.

 

[Sirach38]

No not from my understanding, they envision some anesthesiologists optimizing, overseeing and coordinating the care of the surgical patient throughout the peri operative period.

And what in the world does this mean? I mean, it sounds fancy with words like "optimizing" and "overseeing" but what is the practical application of this? Sounds to me like you'll just be another internist for surgical patients writing all the long H&Ps, dealing with complications, finding placement for patients, rounding on them, seeing them in clinic post-op, etc... Yeah, forget about it. I will subspecialize and do three years of fellowship training if I have to before getting involved in this garbage. You can't pay me enough to be the surgeon's social work slave.

 

[loveumms]

UC Irvine has a very well developed system and it's impressive what they have been able to do in a few short years. U Alabama does too and many PP groups are also developing them (Christina care in Delaware - can't remember the group name). I still believe that this can work for any practice if the right people are interested. I also believe change is coming whether we want to be a part of it or not is up to us.

We do not become the surgeons internists or slaves - I'm not interested in writing endless H&Ps either - I hated medicine clinic and wards. Usually if there is a problem preop (which diabetes is one of the huge issues in our institution), we plan with the internist to get it under better control. I do not write prescriptions and I am not the main person following up with the patient, that is their PCPs job (and they know the patient best anyway so I don't pretend to fill that role). I think of it as I'm a final gate keeper to the patient going for surgery and it's my job to make sure they are optimized (health management, weight, blood pressure, HR control if needed, proper diabetes management, etc). It's not uncommon that I will see a patient with a hba1c >10 come through our clinic. Maybe because we are the final point person for ordering labs and the surgeons are unaware of it until then, not sure how other organizations order labs (if the surgeons are better at catching this).

At my institution we have initiated parts of the surgical home and it has worked well - we still have a lot of work to do but we have various groups working with various surgical teams. We've taken control of most of the pain management issues and are working very hard in our preop clinic to really get patients optimized for surgery. We have completely changed many of pre-op protocols and are aiming to get the patient from the door to OR in less time (by moving the way we do preop influx of patients).

 

[IlDestriero]

Seems like what the surgical PAs are already doing, on their dime. We have a pre op clinic for our end, staffed by NPs with a daily assigned consultant. I'm not sure what more is needed.
When bundled payments come, they still need to pay us, as they can't do the freaking $$urgery without anesthesia.
I don't see much benefit in fighting for the pennies they'll pay for some glorified pre op clinic. And the patients already come to ours.
How long do you think it will take for them to dump everything on us to do and coordinate, including passing on the blame for all but the most obvious surgical problems? About 5 seconds.
Pass.

 

[BuzzPhreed]

My understanding is that the PSH is the system that coordinates the care for a surgical patient from the time a surgeon determines a surgery is indicated through ~30 days post op.

This means that you are on the hook for anything that happens to that surgical patient within that 30 days. It's blame shifting. You know, when that patient goes home and they start smoking again, their dog licks their surgical site, they don't take their medication as directed, and the wind up bouncing back. That is going to be on you now.

No thanks! Like I said, this may be all fine and dandy in the rosy world of academia, but you can't control what the patient does when they walk out the front door. And I, for one, don't want to be blamed for that. Maybe someone out there believes that their patients listen to everything they tell them and do exactly what they say and all love us and hang on our every word. I'm not that naive or arrogant. And I don't want to be blamed for their bad decisions.

This is blame shifting. Nothing more. And it belies a worry in the ASA that we've lost the battle with the CRNAs. So they're trying to "re-invent" our specialty. It's garbage. And I want no part of it.

I'm a realist. Not an idealist. This surgical home crap is idealistic b.s. And it's just going to result in us getting blamed for perioperative surgical complications.

 

[Sirach38]

UC Irvine has a very well developed system and it's impressive what they have been able to do in a few short years. U Alabama does too and many PP groups are also developing them (Christina care in Delaware - can't remember the group name). I still believe that this can work for any practice if the right people are interested. I also believe change is coming whether we want to be a part of it or not is up to us.

We do not become the surgeons internists or slaves - I'm not interested in writing endless H&Ps either - I hated medicine clinic and wards. Usually if there is a problem preop (which diabetes is one of the huge issues in our institution), we plan with the internist to get it under better control. I do not write prescriptions and I am not the main person following up with the patient, that is their PCPs job (and they know the patient best anyway so I don't pretend to fill that role). I think of it as I'm a final gate keeper to the patient going for surgery and it's my job to make sure they are optimized (health management, weight, blood pressure, HR control if needed, proper diabetes management, etc). It's not uncommon that I will see a patient with a hba1c >10 come through our clinic. Maybe because we are the final point person for ordering labs and the surgeons are unaware of it until then, not sure how other organizations order labs (if the surgeons are better at catching this).

At my institution we have initiated parts of the surgical home and it has worked well - we still have a lot of work to do but we have various groups working with various surgical teams. We've taken control of most of the pain management issues and are working very hard in our preop clinic to really get patients optimized for surgery. We have completely changed many of pre-op protocols and are aiming to get the patient from the door to OR in less time (by moving the way we do preop influx of patients).

So this means that surgeons will now have someone doing their preop work AND taking care of their patients for 30 days post op with the blame and burden of their patients now placed on anesthesiologists? This is EXACTLY what the internists at my school do for the orthopods and what midlevels do for many of the other surgical services. Not happy with being compared to midlevels inside the operating room, now we will be trying to do the work of midlevels OUTSIDE the OR?!?! And, unlike the midlevels, our license will now be on the line and we will deal with complications instead of the surgeons?! This is outrageous! It is a step in the wrong direction.

If this takes flight, there will be no better time to be a surgeon even a general surgeon. You operate non-stop and have all the fun in the OR while your slave glorified social workers take care of all your patients and deal with your complications. You leave home when your surgery is done and the anesthesiologist will stay to deal with all the paperwork and continue to "optimize" and "manage" your patient. They also come in early to round on them and you just show up to the OR and start operating.

What a nightmare! THIS is the future of anesthesiology?!?! I can only hope as a med student that if this takes off, it will do so soon so that I can stay far far away from anesthesiology and go into a surgical subspecialty before it's too late.

 

[loveumms]

I don't think anything anywhere says WE (i.e. the anesthesia provider) are on the hook for 30 days postop. The goal will be for us to care for our niche in that time period. None of these PSH groups are managing everything for 30 days postop - that would be truly impossible and no anesthesia provider wants to care for the surgical issues. Many have implemented different ways to help manage the things that anesthesia providers are best at managing and making sure patients remain on 'protocols' (making sure they get out of bed, making sure they get their prescriptions, making sure they understand instructions). Some are really simple, other take additional staff with a physician oversight. The fact of the matter is that if the patient is readmitted, NO ONE will get paid - so really we have a vested interest, along with our surgical colleagues, to make sure this doesn't happen.

I guess my view of the whole PSH project is to improve patient care and patient experience. If I can lend my expertise to helping then why wouldn't I? Because I'm afraid I will get blamed for things out of my control? You are correct, I can't control what patients do when they leave the hospital and I think this is the fault in many of these 'measures' and payment schedules. We have taken away all onus to the patient. It would be nice to see some of these measures start taking into account smoking, obesity and disease management. Several of our surgeons actually refuse to perform elective operations on patients who cannot quit smoking for 30 days in the preoperative period. Required nicotine testing in the office at surgical booking and again in the preop center. If they test positive, thats another 30 day (or more) wait. True, they can't stop patients from re-starting smoking postop but at least it's a start to making patients more responsible for the part they take in their care.

I would ask those who think this is silly what you are proposing we do as a specialty to remain in the place we are now. I think we all know our salaries are going to decrease in the health care model that is being implemented. Sure we are good at taking care of patients in the OR but we still have not shown that we are superior to nurses (and if there is a study or some kind of data that I don't know about, please enlighten me). Its a battle that it would appear we are losing in many states. Maybe data will start showing a difference, maybe it won't. I think the ASA is trying to carve us a niche and I personally think that it can improve the care we provide. Maybe in your institution it won't work and maybe you are still sitting pretty (the nurses are not fighting tooth and nail to get your job). Maybe you are fine taking a pay cut and staying in the OR. Maybe you just don't care and want to pretend like things are not changing. Maybe you think this won't work and it won't do anything for patient care. All of these are fine and we are all entitled to our own opinions. I would just like to hear some alternatives to what is being proposed or why you don't feel an alternative needs to be presented. I ask this with all due respect and out of curiosity.

 

[IlDestriero]

Many have implemented different ways to help manage the things that anesthesia providers are best at managing and making sure patients remain on 'protocols' (making sure they get out of bed, making sure they get their prescriptions, making sure they understand instructions).

How are anesthesiologists better at doing any of those things? I would argue we are worse at all of them, and further, are prone to ignore when the patient is off the "protocol" to keep the surgeons happy and the OR full and making money. Especially outside of the world of academia.

 

[loveumms]

I didn't mean to imply we are better at managing those things - the goal (at least in the PSHs that I've seen) is to make these protocols as a group that standardize certain parts of care - those things I mentioned - then someone (usually an NP) makes sure all the patients are meeting those goals.

We are better at managing pain, fluid management, some diabetes and hypertensive management (not all of it obviously). Of course this could be shared with the internist however, they often don't know enough about operative concerns. You know how many times I've seen an internist write, "consider regional" when it was absolutely impossible or contraindicated. I offered to give our internists a lecture on anesthesia (so they could learn what hey are writing) and no one was interested. that would make me assume they don't want to learn (or maybe don't have time).

 

[dhb]

Personally i think there is some place for increased imput from anesthesiologist during the immediate post operative period for inpatients (first 48h) mostly for pain and fluid management and early recognition of problematic patients. This could be accomplished by a slightly expanded acute pain service.
What i don't see is how our skills can make any difference after this time frame? Do we need to study for 12 years to tell the patients to restart their meds and their physiotherapy? Nor is this usefull nor is it a source of revenue for us.

 

[urge]

I noticed I'm not the only one who does not have clear what a surgical home is. From the get go seems like it is going to be a flop if people don't when know what it is.

I don't get the difference between having a preop clinic and beeing a surgical home. Let's say instead of getting a "clearance" by his cardiologist, now we channel the patient through in-house specialist and sign off on it as a last step in the clinic. Seems like our role is actually diminished. We are basically handing off the preop process to in-house internists and just saying hello after all the work has been done.

I don't know how this is an improvement from current practice. The hospital internists benefit, not us.

I don't understand the post op 30 days. What are we supposed to do? Make sure they are back on their pills and insulin. Do we really need 30 days for that?

Seems like the surgical home is a plan to eliminate stand alone medicine doctors. I can see the hospitals supporting that. I don't know how the patient benefits or what additional service we anesthesiologist we provide them.

Once the hospital gets control of the patient stream, they will ask for the lump sum payment to get control of the physician's revenue stream.

 

[deleted171991]

Seems like the surgical home is a plan to eliminate stand alone medicine doctors. I can see the hospitals supporting that. I don't know how the patient benefits or what additional service we anesthesiologist we provide them.

I said it already and I will say it again: in my view, the PSH tries to change the anesthesiologist into a surgical hospitalist/NP coordinator, so that the surgeon can stay more in the OR and make more money for the hospitals, fewer surgeries get cancelled, fewer patients get readmitted etc. I wouldn't be surprised if it came with call requirements, so that the dear valuable patient-bringing surgeons can rest more than the worthless expensive overqualified anesthesiologists.

This is the ASA's PSH overview:

 

[IlDestriero]

I noticed I'm not the only one who does not have clear what a surgical home is. From the get go seems like it is going to be a flop if people don't when know what it is.

I don't get the difference between having a preop clinic and beeing a surgical home. Let's say instead of getting a "clearance" by his cardiologist, now we channel the patient through in-house specialist and sign off on it as a last step in the clinic. Seems like our role is actually diminished. We are basically handing off the preop process to in-house internists and just saying hello after all the work has been done.

I don't know how this is an improvement from current practice. The hospital internists benefit, not us.

I don't understand the post op 30 days. What are we supposed to do? Make sure they are back on their pills and insulin. Do we really need 30 days for that?

Seems like the surgical home is a plan to eliminate stand alone medicine doctors. I can see the hospitals supporting that. I don't know how the patient benefits or what additional service we anesthesiologist we provide them.

Once the hospital gets control of the patient stream, they will ask for the lump sum payment to get control of the physician's revenue stream.

You don't turn him over to some hospitalist, you take him over yourself to coordinate preop and post op care. The surgeon just becomes a cog in the wheel cutting away and moving on to the next. Like IR is now. IR has no patients. They eval patients when consulted for procedures then do them and move along to the next one.

 

[deleted171991]

You don't turn him over to some hospitalist, you take him over yourself to coordinate preop and post op care. The surgeon just becomes a cog in the wheel cutting away and moving on to the next. Like IR is now. IR has no patients. They eval patients when consulted for procedures then do them and move along to the next one.

Exactly. Instead of the anesthesiologist being the consultant, it's almost like the surgeon is.

The ASA is patting themselves on their back, because it's one of the ways anesthesiologists will still have a job once independent CRNAs infest every subspecialty and state. Also, in the ACO era when what matters is who brings money/patients to the hospital, we could make them money indirectly by giving surgeons more time to operate and by decreasing perioperative costs for optimizing patients.

The next step is to replace surgeons with PAs for certain procedures, a la ACT model, and the OR assembly line is complete. It's a planned destruction of independent medical practice of any kind, and replacing everything with "teams". Regular corporate male bovine excrement. It's much easier to rule over a chorus than a bunch of prima donnas.

The one really good thing that could come out of this is that we can become way more entrenched in hospital physiology, outside of the OR, and especially in surgical services administration, while surgeons will be busy operating. So instead of the Chief of Surgery running the show, the Chief of Anesthesia/PSH will.

 

[BuzzPhreed]

Exactly. Instead of the anesthesiologist being the consultant, it's almost like the surgeon is.

Orthopedic surgeons have been doing this for some time now. The Internal Medicine doc takes care of all of the "medical" problems. The surgeon just does the operation.

Talk about having your cake and eating it too. Again, I want no part of it. This represents "tossing in the towel" by the ASA.

Pony up... or shut up.

 

[Sirach38]

Exactly. This is not the answer to the future. Anesthesiologists don't have to "change" the profession to cater to some nurse. It's this stupid mentality of bending over for these stupid militant nurses that got us in the predicament in the first place. The only thing we need to change about the specialty is the push-over cowardly mentality many physicians within the field have. MDs must fight for their position in the OR tooth and nail until the very end. Educate the public, use propaganda if we have to like the nurses do, make sure everyone in the country is aware that hospitals are willing to risk patient's lives to save a few pennies. In some polls, 90% of the patients state that they want a physician supervision all aspects of anesthesia care and 70% believe ONLY physicians should be part of this care. The public must be educated on the situation through whichever means are necessary. That will put pressure on surgeons and administrators to do what is right for patients.

Come on guys, we are going to bend over and take it from nurses with less than 1/10 our education? This is utter BS.

 

[urge]

You don't turn him over to some hospitalist, you take him over yourself to coordinate preop and post op care. The surgeon just becomes a cog in the wheel cutting away and moving on to the next. Like IR is now. IR has no patients. They eval patients when consulted for procedures then do them and move along to the next one.

Not sure how this is going to play out. Let's assume that you take over the complete preop and post op process. Basically you notice he has SOB on exertion and his BP & glucose is high, and send him to an internist to have that worked up. I'm not sure what was your grand role in the whole thing if you had someone else fix the issues, but let's go on. You approve him for surgery and let's assume everything goes well. The patient spends a few days in-house in which you round like an internists making sure his labs are ok, his x rays were done, coordinate PT and social work..... Patient goes home and you keep calling him and listening to a long litany of complaints every couple of days for a month...

How many days out of the OR were you for this, staffing the preop clinic and the ward?

Can you maintain your competency in anesthesia by being in the preop clinic and the ward that often? Who do you think will be better, the anesthesiologist doing cases every day, or the one that comes part time when not taking care of periop issues?

Most likely it will be designated people doing periop all the time ( or most). But, can these designated people still be called anesthesiologists if they don't really provide anesthesia? They are functioning like a hospitalist, or a PA to tell you the truth. Then, why not get a hospitalist, or PA, to do it, and let the anesthesiologist focus on providing anesthesia?

The more we stretch out our services, the lower the quality in my opinion.


Palo Alto VA Periop Surgical Home:

Every day a dedicated anesthesiologist visits all inpatients who underwent surgery and/or anesthesia the day prior and continues to follow those patients with unresolved medical issues as needed. We often interface with the patient's ongoing care team that includes surgeons, intensivists, and primary internists/subspecialists. Patients and their families have ample time to ask questions and have any unmet needs addressed. We pay special attention to anesthetic sequelae, the inpatient management of chronic medical conditions, and pain control in our patients.

 

[Libertas]

Every time I've heard about this concept, it's spoken of in vagueries and platitudes. (Including at the asa opening speech). I'm still waiting for the nitty gritty of what the surgical home really means. I'd be curious to hear about the Irvine model.

 

[kazuma]

I know many folks hate rounding and enjoy the lack of it in the OR, but those of us doing CCM don't mind rounding some of us might even enjoy it. Not everyone needs to round, reportedly the majority of folks will continue to practice OR anesthesia the way they do now but with perhaps more supervision (4+ rooms), and likely in an employed position by a hospital or AMC.

 

[DaTruMD]

I know many folks hate rounding and enjoy the lack of it in the OR, but those of us doing CCM don't mind rounding some of us might even enjoy it. Not everyone needs to round, reportedly the majority of folks will continue to practice OR anesthesia the way they do now but with perhaps more supervision (4+ rooms), and likely in an employed position by a hospital or AMC.

Employed? Does that mean anesthesiologists can at least form a union?

 

[kazuma]

Apparently, if the Oregon hospitalists are successful with their union. I thought there were laws against physicians unionizing.

 

[Arch Guillotti]

Apparently, if the Oregon hospitalists are successful with their union. I thought there were laws against physicians unionizing.

There are but they apparently don't include employees.

 

[loveumms]

It's worth looking into the UC Irvine program - whats being projected above is not at all what they explained to us. We had Dr. Kain come to our institution like a year ago and I sat down with him for an hour after the grand rounds to discuss their implementation and how they made it work. I then went to the first perioperative summit and found many ideas that are working in several institutions (both academic and private practice).

Maybe there are some residents at UC irvine that can give a better picture then I (since it was a year ago). They have a well oiled machine that started with the total joints and has now moved into other surgical specialties. The joint program decreased hospital length of stay and improved patient satisfaction. They do NOT round on every patient and in fact, the physicians don't really round much at all on the post-op patients. There is a PSH resident and attending on every day that deal with 'issues' that the NP finds through rounding. They see these patients exclusively. Yes, they do have a phone number for patients to call but because they start educating their patients on realistic expectations (and planning properly) from day 1 of booking the surgery, they don't get very many calls.

I still am asking - what is your alternative????? Sure, I can educate patients all I want (and I often do introduce myself as doctor and explain when I'm working with a nurse/residnet that I'm overseeing the care and sometimes if they re interested will talk about the differences) but I don't think that is going to cut it for us in the end and I certainly don't have time to do that when I'm seeing 50+ patients in the clinic or running two very busy ORs. And everyone keeps putting the nurses down but where is the research that the care they give is inferior to ours? Maybe that will be the key to really differentiating ourselves (and with more states trying to gain opt-out status maybe it will become more clear ... or maybe it won't). I just think with managed care and the encroachment on our speciality we will need to broaden out care.

Some of the other physicians that have lectured to us in the past year have stated that the surgeons role is to perform surgeries - thats it. It's our role to get the patient prepared for surgery and through the operative period. I'm not sure if I agree with this statement and most of our surgeons were offended when a well known anesthesiologist from a big name institution stated this at our combined anesthesia-surgery grand rounds. Our surgeons still want to take care of their patients (of course there are ones who don't and just want to operate). As a resident I would get offended when the ortho resident didn't know how to manage hypertension or diabetes. Now I'm starting to think that maybe they should just concentrate more on the surgical aspect of patient care - they just don't have the time when it's a very busy surgical and they are in the OR 18 hours a day (of course they could operate a little faster but thats another issue altogether). We have some really talented surgeons who prepare patients for surgery and are really involved, we have others who are don't care about the management and preparation. I guess I'm coming around to realize that I'm probably better equipped to deal with some of the preoperative issues (although we are now seeing 50+ patients a day in our preop clinic so I might not feel that way in the coming months).

 

[urge]

I still am asking - what is your alternative?????

I would have a group of hospitalists evaluate the patient and have an anesthesiologists go over it in the preop clinic to formulate a plan and explain it to the patient. Let the surgeon operate and the anesthesiologist anesthetize, and have the hospitalists admit the patient under their care. Post op anesthesia visit as usual. Pain team follow up for those needed only. Post op surgical input as needed.

That's it. How is that complicated? Why do we have to make a big deal out of it?

Can we name this Periop Surgical Palace?

BTW, I suppose we could create a hospitalist fellowship for anesthesiologists who don't like being in the OR that much but that will be ready 10 yrs down the line.

 

[Ignatius J]

No not from my understanding, they envision some anesthesiologists optimizing, overseeing and coordinating the care of the surgical patient throughout the peri operative period. The majority of anesthesiologists will continue to work in the OR as they do today. Yes, it's a new idea and dramatic shift from current practices but I haven't heard of any other reasonable solutions as to how anesthesiologists are to remain relevant with the advent of ACO's and bundled payments etc. Whether we like it or not, the way we practice medicine and are reimbursed in the future is changing. That part is out of our control, we can either evolve and adapt to the new environment or let somebody else fill the niche while we allow the specialty to become marginalized.

Honestly, do you have any experience with what you're talking about? I have seen ZERO moves in our market for reimbursing for the anesthetic. CMS is always good for tinkering with rules and what not, but I think you are being very presumptuous. VERY presumptuous.

 

[kazuma]

Honestly, do you have any experience with what you're talking about? I have seen ZERO moves in our market for reimbursing for the anesthetic. CMS is always good for tinkering with rules and what not, but I think you are being very presumptuous. VERY presumptuous.

Personal experience with an ACO? No our hospital is not an ACO, but as mentioned earlier, there are a number of ACO's in PP and academics. This number will continue to grow as its apart of the ACA/Obama care and I think its safe to say that the ACA is not going to be repealed. My experience with an ACO limited to the articles I've read, a couple dozen lectures over the years and conversations Ive had with ASA leadership. This topic had been discussed in detail and I think its a good idea. Perhaps y'all have top notch hospitalists at your shop, but we certainly don't. We are constantly finding medication errors, inpatients not adequately optimized in Pre-op, even full blown DKA has been diagnosed in presurgical patients awaiting to go back to the OR. We need someone to oversee surgical patients so they don't fall through the cracks.

 

[deleted126335]

Exactly. This is not the answer to the future. Anesthesiologists don't have to "change" the profession to cater to some nurse. It's this stupid mentality of bending over for these stupid militant nurses that got us in the predicament in the first place. The only thing we need to change about the specialty is the push-over cowardly mentality many physicians within the field have. MDs must fight for their position in the OR tooth and nail until the very end. Educate the public, use propaganda if we have to like the nurses do, make sure everyone in the country is aware that hospitals are willing to risk patient's lives to save a few pennies. In some polls, 90% of the patients state that they want a physician supervision all aspects of anesthesia care and 70% believe ONLY physicians should be part of this care. The public must be educated on the situation through whichever means are necessary. That will put pressure on surgeons and administrators to do what is right for patients.

Come on guys, we are going to bend over and take it from nurses with less than 1/10 our education? This is utter BS.

At its peak at the end of the 19th century, the U.S. ice trade employed an estimated 90,000 people...

http://en.wikipedia.org/wiki/Ice_trade

I am sure they said the same thing.

 

[deleted171991]

At its peak at the end of the 19th century, the U.S. ice trade employed an estimated 90,000 people...

http://en.wikipedia.org/wiki/Ice_trade

I am sure they said the same thing.

I just LOVE this post.

And that's why I am going into CCM.

 

[EtherBunny]

Despite all of the objections, I'm a proponent of the perioperative surgical home.

Given the relentless political agenda of the AANA, the Institute of Medicine report on scope of practice, mounting cost containment pressures, and the rising tide of "opt out" states, now (more than ever) anesthesiologists need to demonstrate their value in health care settings. Anesthesiologists need to have a pervasive presence in health care settings, playing a key role in every step of the continuum of perioperative care.

Preooperative care needs to extend well beyond the day of surgery. I think it's crazy that anesthesiologists are expected to meet patients for the first time on the day of surgery! How can you establish a relationship with the patient? How can you gain the patient's trust quickly? Emergency surgeries are an obvious exception, but for elective surgeries? Anesthesiologists, like surgeons, should have some ownership of patients, and the only way to do that is to be involved in the clinic setting.

I can imagine a situation, in which an anesthesiologist is "embedded" (for lack of a better term) in one or more surgical clinics. Any patients who are deemed surgical candidates on a given day would be seen by the anesthesiologist the same day. Scheduling would then be created in a way that the same anesthesiologist would be supervising the patient's anesthetic. That's how anesthesiologists can get some degree of ownership in the process. In addition, this is how very close bonds can be formed between anesthesiologists and surgeons.

Preoperative testing would be controlled exclusively by anesthesiologists. No more unnecessary testing, which only serve to increase the overall cost of care. Preoperative optimization would be controlled by anesthesiologists. Anything that falls outside the anesthesiologist's comfort zone would warrant consultation. The average anesthesiologist knows a ton of medicine. It's not unreasonable to expect an anesthesiologist to handle the lion's share of preoperative optimization.

Intraoperative logistics would be under the purview of anesthesiologists, involving the appropriate supervision (or lack thereof at the anesthesiologist's discretion). High acuity patients may warrant 1:1 supervision whereas a bunch of low acuity patients in low risk surgeries may only require 1 anesthesiologist supervising 10 CRNAs. What's more, many cases may not require any supervision, but that decision should be up to the anesthesiologists at a particular facility.

Immediate postoperative care (the first 24-48 hrs maybe?) would also be controlled by anesthesiologists.
Then things could be transitioned to hospitalists. Anesthesiologists get a huge dose of critical care in training. Why on earth would you NOT want an anesthesiologist handling the immediate postoperative setting?

I don't understand why people are opposed to this idea. Anything that gets anesthesiologists more inextricably involved in the process of perioperative care is a good thing, because that's what makes people in organizations irreplaceable. With all of the AMCs on the horizon and CRNAs desperately trying to gain more traction in the intraoperative setting, this is a godsend.

Just my $0.02.

 

[Baller MD]

At its peak at the end of the 19th century, the U.S. ice trade employed an estimated 90,000 people...

http://en.wikipedia.org/wiki/Ice_trade

I am sure they said the same thing.

Will lawyers be okay with suing nurses when things go wrong? Will nurses be willing to be legally held accountable? What about surgeons?

I feel like anesthesiologists will have a place in the OR as long as lawyers want money.

 

[Sirach38]

Despite all of the objections, I'm a proponent of the perioperative surgical home.

Given the relentless political agenda of the AANA, the Institute of Medicine report on scope of practice, mounting cost containment pressures, and the rising tide of "opt out" states, now (more than ever) anesthesiologists need to demonstrate their value in health care settings. Anesthesiologists need to have a pervasive presence in health care settings, playing a key role in every step of the continuum of perioperative care.

Preooperative care needs to extend well beyond the day of surgery. I think it's crazy that anesthesiologists are expected to meet patients for the first time on the day of surgery! How can you establish a relationship with the patient? How can you gain the patient's trust quickly? Emergency surgeries are an obvious exception, but for elective surgeries? Anesthesiologists, like surgeons, should have some ownership of patients, and the only way to do that is to be involved in the clinic setting.

I can imagine a situation, in which an anesthesiologist is "embedded" (for lack of a better term) in one or more surgical clinics. Any patients who are deemed surgical candidates on a given day would be seen by the anesthesiologist the same day. Scheduling would then be created in a way that the same anesthesiologist would be supervising the patient's anesthetic. That's how anesthesiologists can get some degree of ownership in the process. In addition, this is how very close bonds can be formed between anesthesiologists and surgeons.

Preoperative testing would be controlled exclusively by anesthesiologists. No more unnecessary testing, which only serve to increase the overall cost of care. Preoperative optimization would be controlled by anesthesiologists. Anything that falls outside the anesthesiologist's comfort zone would warrant consultation. The average anesthesiologist knows a ton of medicine. It's not unreasonable to expect an anesthesiologist to handle the lion's share of preoperative optimization.

Intraoperative logistics would be under the purview of anesthesiologists, involving the appropriate supervision (or lack thereof at the anesthesiologist's discretion). High acuity patients may warrant 1:1 supervision whereas a bunch of low acuity patients in low risk surgeries may only require 1 anesthesiologist supervising 10 CRNAs. What's more, many cases may not require any supervision, but that decision should be up to the anesthesiologists at a particular facility.

Immediate postoperative care (the first 24-48 hrs maybe?) would also be controlled by anesthesiologists.
Then things could be transitioned to hospitalists. Anesthesiologists get a huge dose of critical care in training. Why on earth would you NOT want an anesthesiologist handling the immediate postoperative setting?

I don't understand why people are opposed to this idea. Anything that gets anesthesiologists more inextricably involved in the process of perioperative care is a good thing, because that's what makes people in organizations irreplaceable. With all of the AMCs on the horizon and CRNAs desperately trying to gain more traction in the intraoperative setting, this is a godsend.
Just my $0.02.

While I don't agree with every part of this post, the one idea that I love is patient ownership. If anesthesiologists could split patient ownership with the surgeon it would do an amazing thing for the specialty. It would be great if patients knew their anesthesiologist and could pick him/her ahead of time instead of being assigned one the day of surgery. This may help patients become more familiar with the role and value of an anesthesiology and may make it harder for doctors to be replaced by nurses.

On the other hand, what's going to stop encroachment on this turf by CRNAs? What if an AMC decides that they will now provide "low cost" perioperative services by supplying all of those preop clinics with CRNAs. It seems like midlevels will have no problem stepping into these roles as currently, a lot of midlevels already do these things under the supervision of surgeons.

 

[deleted126335]

Will lawyers be okay with suing nurses when things go wrong? Will nurses be willing to be legally held accountable? What about surgeons?

I feel like anesthesiologists will have a place in the OR as long as lawyers want money.

Nice. According to you, our best hope is the ambulance chaser. I guess that you are against tort reform?
There will always be a place for anesthesiologists in ORs.

The questions are:
How many will be needed? Answer: Most likely Fewer.
What type of place? Answer: Quite a bit different than most of us are used to.

 

[Baller MD]

Nice. According to you, our best hope is the ambulance chaser. I guess that you are against tort reform?
There will always be a place for anesthesiologists in ORs.

The questions are:
How many will be needed? Answer: Most likely Fewer.
What type of place? Answer: Quite a bit different than most of us are used to.

I am not against tort reform. I'm an MS3 planning on applying to anesthesiology. I just want the field to be in a good position by the time I'm finished training. I guess I was trying to justify, perhaps incorrectly, why anesthesiology will continue to have it relatively good.

 

[EtherBunny]

While I don't agree with every part of this post, the one idea that I love is patient ownership. If anesthesiologists could split patient ownership with the surgeon it would do an amazing thing for the specialty. It would be great if patients knew their anesthesiologist and could pick him/her ahead of time instead of being assigned one the day of surgery. This may help patients become more familiar with the role and value of an anesthesiology and may make it harder for doctors to be replaced by nurses.

On the other hand, what's going to stop encroachment on this turf by CRNAs? What if an AMC decides that they will now provide "low cost" perioperative services by supplying all of those preop clinics with CRNAs. It seems like midlevels will have no problem stepping into these roles as currently, a lot of midlevels already do these things under the supervision of surgeons.

Anesthesiologists, as physicians, will stand head and shoulders above ANY CRNA when it comes to preoperative assessment, especially of the undifferentiated patient. Physicians are the gold standard when it comes to the diagnosis and formulation of treatment plans for disease. If the goal is to perform an excellent history to generate a preliminary differential diagnosis, perform a focused but effective physical examination to test the hypotheses on the differential, and to RATIONALLY order tests to clinch the diagnosis, a physician is hands-down the best option. We have (by far) the most training in this area. Also, when it comes to formulating treatment plans, again, physicians are the gold standard. We have FAR more training in the complex process of weighing risks and benefits to create a rational, evidence-based, and (hopefully) effective treatment plan. We are tested to death on this process--every single day on the wards as a medical student, intern, and resident emphasizes this skill set. "Optimizing" medical conditions for surgery is just another iteration of formulating a treatment plan.

Invasive lines and monitors, regional, airway management--these things aren't what separate anesthesiologists from CRNAs (it used to be the case, but not anymore). What separates anesthesiologists from CRNAs is the extraordinary depth of our medical training in the diagnosis and management of a wide variety of diseases. This is what the ASA needs to capitalize on in their efforts to implement a "perioperative surgical home."

 

[Planktonmd]

It is really sad when our professional organization which is supposed to defend our specialty, sees the future anesthesiologist as a specialist in everything except anesthesiology!
There is a reason why AMCs and hospital CEOs love the concept of the "surgical home", it allows them to use anesthesiologists as free labor to replace other expensive specialists, but for the ASA to pioneer this crap and market it on their behalf is simply outrageous!

 

[IlDestriero]

And when we farm duties out to NPs, PAs, hospitalists, CRNAs, etc. they will say it is an anesthesia expense and want us to pay for it as well.

 

[DocOk]

Sounds a lot like a modified European type of practice of an anesthesiology, and less like a new idea. In theory it makes sense but I wonder about the difficulty in implementation. I personally see this all the time patients needing "clearance" from specialist xyz for no real defined reason. But who understands the stress of surgery and the physiological changes better than an anesthesiologist? Why would you not want them captaining you through this surgical period?

 

[deleted171991]

.

Sounds a lot like a modified European type of practice of an anesthesiology, and less like a new idea. In theory it makes sense but I wonder about the difficulty in implementation. I personally see this all the time patients needing "clearance" from specialist xyz for no real defined reason. But who understands the stress of surgery and the physiological changes better than an anesthesiologist? Why would you not want them captaining you through this surgical period?

Because anesthesiologists will be paid **** for this. It will be part of the usual OR anesthesia fees. That's why it didn't happen in the past, and that's why they'll have a difficult time selling it now.

American hospital executives care only about their bonuses, while banging their chests about all the money they are saving (by screwing the doctors). The more they decrease costs, the more bonuses they get. This is also the reason why the Press-Ganey crap is so important to them (executive bonuses tied to PG scores). It has nothing to do with improving care; that's just a pretext.

PSH is an easy way to squeeze anesthesiologists even more, while giving the surgeons more time to operate, hence to make money for the "non-profit" corporation. What's not obvious?

We all love capitalism until it's used against us.

 

[BuzzPhreed]

I 100% agree with what you said above, FFP. Except for this...

We all love capitalism until it's used against us.

This isn't capitalism. This is people using lobbying and legislative muscle (regulation and tax protection, especially in the not-for-profits) to protect themselves. They don't want pure capitalism.

Just look at what the "big car" industry is trying to do to Tesla as an example.

http://www.teslamotors.com/sv_SE/forum/forums/so-im-little-confused-direct-sales-limitations-tesla

And the ice trade thing is a straw man argument. Ice was a commodity back in the late 19th century. A new technology rendered it obsolete. It's the same thing that happened to Kodak. Your analogy would only be true if there was a brand new perfect invented medication that you could give to the patient and do a surgery on them without monitoring them, etc. In anesthesia you still need people to give the drugs (i.e., "ice").

 

[Ipassgas]

Etherbunny, I'm betting you work at the Mecca, or in a very high density city.

I'm in the hinterlands, fly over country, boondocks, etc. There are no clinics in the hospital. There is a medical office building across the street. None of the surgeons have an office there. On a map, it's over 50 miles between the 2 furthest apart remote clinic sites.

I can't sit in one all day to see 5 patients, and i can't drive all over the county every time a surgeon calls and says hey, I'm booking a case for three weeks from now.

To call that ridiculous would be an understatement. Then, to assure I'm covering their case later? Ha, ha, ha. I mean, that's laughable.

There is a reason the preop preperation is done from the hospital, in a large closet off the pre op holding area. At least here in the sticks.