How do we preserve the future of anesthesia?

[criticalelement]

No, of course not. Then again, there aren't other physicians fighting to deliver anesthesia in the OR, either, so this is a bit of a false dichotomy.

What I think is not in dispute:

1) ASA 1-2 can probably be safely staffed by CRNAs with appropriate-ratio anesthesiologist oversight. Higher acuity cases merit an anesthesiologist providing care directly. THIS IS AN ISSUE WE SHOULD BE FIGHTING TOOTH AND NAIL.

2) The specialty has been substantially diluted by the ASAs lack of effort, and, as others have pointed out, muddy motives on the part of the society's leadership and many in PP who have gotten rich along the way.

3) We keep turning out more and more anesthesiologists.

4) There is an intensivist shortage.

When I add up 1-4 I don't see a strong case for PSH and trying to steal food out of the mouth of the hospitalists (unless you really believe that it will somehow protect us when bundled payments come... And I don't. Anesthesiologists will just have ended up doing more work for the same/less money). I do, however, see a compelling case to encourage push the future of the specialty towards training intensivists.

Half tongue-in-cheek, but nobody calls an intensivist doc "hey ICU". I think this says a lot.

PS - the ultimate ad campaign would be to have a picture of Bill Clinton with a caption like "Even though Bill Clinton's mom was a nurse anesthetist, when the president had surgery, he chose a physician anesthesiologist." Make the point unequivocally -- when you want the highest possible odds of a good outcome (and everyone going in to the OR does), there's one "right choice".

Where is there an intensivist shortage? Most people who go into anesthesia do it to get out of the icu

---

Members don't see this ad.

 

[Psai]

I'm still waiting for the SIMPLEST publicity campaign in the world: "Who would you rather have taking care of you when you go under, a physician or a nurse?" Are they scared to get their hands dirty? Scared they will offend someone on the other side? Taking the higher road is what has led this specialty into the state that it is in today, and the fact that none of them have learned from the past (and present) is pathetic.

The ASA is getting crushed both publicly and politically by the nurses, and it truly speaks to the cowardice and idiocy of our so-called "leaders."

Hm this or the "perioperative surgical home" filled with bs that every anesthesiologist goes into anesthesiology to avoid. Hmmmmm
Better spend some cash on new headquarters. Give me money.

 

[ZzzPlz]

The future of both medicine and anesthesia:

Uh oh
CRNPA's

 

[chocomorsel]

I am against the surgical home.

Why?

Not because I dont wanna do the work, which I don't, but I don't want to take the thinking away from the surgeons. I want the surgeons to know about their patients. I love asking the orthopedica surgeons, How is Ms. jones asthma doing? Did you give her preop albuterol? Is she wheezing? Do you think i should give her steroids in the OR? How is Mr. Smith's Afib doing? Did you stop the coumadin? etc etc.. That is their job, and if they cannot do it, they should enlist some folks to help them in the form of INTERNISTS.

This is so funny to me.
Why? Many, if not most surgeons are clueless when it comes to their patient's comorbidities. All they care about is for us to agree to put them to sleep so they can cut away. I know more about the patient any given day than the surgeons and I just met the patient 10 minutes before. While the surgeon has seen them weeks before, more than once but doesn't know much.
It's unfortunate actually.

And yes, I think we would do well in this whole surgical home. We are the ones who make sure that the patient is ready to go for surgery. We clear the patient's no matter how often the surgeons think that the PCP's and the Cardiologists do. We can work in conjunction with the PCP's and the IM specialists to make sure the patient is in top notch on the day of surgery. This will lead to less cancellations on the day of surgery for patients who are not well optimized.
That being said, we would need to get paid for it.

Lastly, we need to be more involved in the ICU as one other poster has said. Lets face it, if the ICU reimbursed more than the OR I bet a lot more anesthesiologists would be interested in pursuing it. I believe this makes us a completely rounded physician who could work anywhere in the world and run the ICU's as our peers do in other countries. Didn't the whole intensive care training get started by anesthesiologists? In this country, the anesthesia docs prefer to be in the OR because that's where the money is. Sure some people hate the unit, but lets face it, how many folks in the Unit are awake, and talking and bothering you? There is not much interactions with patients. They are mostly sedated, and sick as hell. How's that any different that the ASA 4-5 patient in the OR that you are trying to keep alive while they are undergoing surgery? Except that you take care of them over days to weeks, versus hours. There is not much dispo except when better, move them to stepdown, floor, or morgue if dead. Anesthesiologists have the fundamental and background training to be awesome ICU docs. We should embrace that more instead of running away. After all, there is a shortage of intensivists. Why fight with nurses, when we could branch out and feel the ICU needs?

I work in an MD only model, and would be fine working in an ACT model as long as I got to do my own cases about half the time. But when s hit really starts going south, I will line up to be an ICU fellow. Probably sooner rather than later.

 

[Baller MD]

.

 

[repititionition]

Where is there an intensivist shortage? Most people who go into anesthesia do it to get out of the icu

http://www.ncbi.nlm.nih.gov/pubmed/24132037

and pages of results from a google "intensivist shortage" search.

anesthesiologists not wanting to do the work doesn't mean there is no shortage. As is mentioned above, the calculus would probably be different if the ICU paid the same as OR work.

 

[TeslaCoil]

I'm still waiting for the SIMPLEST publicity campaign in the world: "Who would you rather have taking care of you when you go under, a physician or a nurse?" Are they scared to get their hands dirty? Scared they will offend someone on the other side? Taking the higher road is what has led this specialty into the state that it is in today, and the fact that none of them have learned from the past (and present) is pathetic.

The ASA is getting crushed both publicly and politically by the nurses, and it truly speaks to the cowardice and idiocy of our so-called "leaders."

I'm for taking the proverbial gloves off myself... perhaps a new organization should be founded: "The American Association of Anesthesiologist Physicians". An organization more inclined to do what needs to be done? No CRNA's allowed, and not to make an enemy out of them, but simply to protect our best interests as physicians. I like the idea of getting the public more involved... most lay people I ask would much rather have a physician running their anesthesia... but it wouldn't even have to read physician or nurse, it could read: "Would you rather have a physician supervising your anesthesia care directly, or would you rather have a nurse administering anesthesia independently?" I think that gets the job done equally well without making an enemy out of every CRNA out there...

 

[Urzuz]

Because you don't want to bite the hand that feeds you. Supervising 4 rooms make a lot of anesthesiologists rich. If physicians are that much better then why are you splitting your attention between 4 patients at a time? Do the patients even know that you are supervising 3 other cases in addition to theirs? Put your money where your mouth is and go back to physician-only anesthesia. The problem is that there are a lot of old-timers out there that couldn't do a simple case by themselves if their life depended on it.

The bad PR that the ASA is getting crushed on was brought upon by themselves. There are ways to improve the image of the specialty, but that would mean presenting ourselves as physicians to the patients and rest of the staff and not just chart-signers.

I hate to break it to you, but not a single healthcare worker, including the janitor that mops the floors between cases, gives two ****s as to whether you're a physician or not. As long as the patient has a pulse in the PACU, NO ONE can measure the outcome difference between a fellowship-trained cardiac anesthesiologist and an CRNA fresh out of training (or sorry, I guess it is residency now?). The ONLY person who you have a legitimate chance of convincing that a physician is better than a murse is the patient. And you hope that in convincing patients, it will lead to convincing legislators that this is a real issue. And keep in mind you can't even do this based on data. You do it based solely on fear alone, eg: who would you rather have, a physician or a nurse taking care of you?

The example I gave isn't supposed to be the epitome of a perfect campaign by the ASA -- it is an example of something SIMPLE that will keep anesthesiologists relevant in patients' intraoperative care. It doesn't have to be physician-only anesthetic care, but at least it adds credence to the idea that an anesthesiologist should be involved in their care in some way (either directly or through supervision). It will do something to stifle the push for independent CRNA practice. Is this the silver bullet? Of course not. Anesthesiologists DO have to get off their fat asses and step up to the plate, becoming involved politically at hospital, regional, and national levels, take more ownership/responsibility for their patients, and become relevant outsider of just the operating room. But this has to be done in conjunction with educating the public as to what is going on behind closed doors, and how the only thing that matters to hospital administrators is the bottom line, and not their safety.

And as an aside, I am going to assume you meant the metaphorical "you" in your post and did not actual mean me....because I actually AM a part of a physician-only anesthesia group and wouldn't have it any other way. And as for those old-timers who can't do a case if their lives depended on it? Those are the same ones that will happily sell an anesthesia group filled with young bloods to an AMC for a fat check and a slightly earlier retirement. So good riddance to them.

 

[TeslaCoil]

The data we need is not total outcomes with supervision vs total outcomes without supervision, that data says nothing useful given the low rates of complications nowadays. Its outcomes of complicated cases specifically, where there are only nurses involved vs when there is a physician present. I would venture to say that in the rare instances when the **** hits the fan, outcomes would be better when there is a physician present. Has anybody heard of this short of data being looked at in any way?

 

[Spinach Dip]

I like the idea of getting the public more involved... most lay people I ask would much rather have a physician running their anesthesia...

In my experience, the vast majority of Americans (something like 75+%) don't even know what a CRNA is.

The first step to any serious campaign would be to inform the American public of the nature and cause of the problem. As soon as they are invested (but not before), there will be a chance to actually change things.

 

[Planktonmd]

Its a matter of access to anesthesia. If we went phyician only everywhere, we would have to train 5-7 thousand anesthesiologists every year. Think about that number. Do you think CMS can stomach footing that bill. the next best thing is the care team as we know it. That is being threatened too now.

When the ASA has the balls to openly issue a statement that any anesthetic done without the supervision of an anesthesiologist does not meet the society's standards and is not endorsed by the ASA then everyone will have to listen including the government, insurance carriers and malpractice lawyers.
All it takes is this simple statement but a corrupt entity like the ASA will never be capable of such move.

 

[pgg]

The data we need is not total outcomes with supervision vs total outcomes without supervision, that data says nothing useful given the low rates of complications nowadays. Its outcomes of complicated cases specifically, where there are only nurses involved vs when there is a physician present. I would venture to say that in the rare instances when the **** hits the fan, outcomes would be better when there is a physician present. Has anybody heard of this short of data being looked at in any way?

The data that exists is retrospective with many confounders. That's why the AANA is able to cloud the issue and make the claims they do ... the data is of poor quality, and the AANA's funding / publication bias is a thumb on the scale that is used to deliberately muddy things further.

There's no way a well designed prospective, randomized trial would get past an IRB, much less the consent process. How do you get a patient to agree to "nurse anesthesia with no help or backup from a doctor" rather than "physician anesthesia"? No person would agree to that, if given a choice free of pressure and economic influence.

To say nothing of the ethical problems with randomizing complex patients to what you believe is inferior care, and then being willing to let the CRNA hang alone, no matter what happens, just to prove it.

The study will never be done.

 

[GravelRider]

You know, I think we are all dancing around the same goal, but with different ideas on how to achieve it. The key is more involvement in care for the patient. That is what we need to get the ball rolling in order to earn more political capital. Meeting a patient 10 minutes before a surgery and acting like you are in a rush and then having the patient never see you again is not going to cut it. The PSH, while definitely a contrived idea of the ASA, is an idea that attempts to push anesthesiologists in the direction of being more involved in a patient's care. We NEED patients to know that we are thinking about their surgery and doing everything we are trained to do to get them through it safely. In our heads we know that we have created a safe anesthetic plan, but the patients need to know that as well...and preferably more than 10 minutes prior to the procedure. We need to show patients that CRNAs are under our direction and not just there in case something goes wrong.

We need increased visibility for both patients and for our surgical colleagues. That is what it all comes down to. If you have a better idea than the PSH then I am all ears.

 

[repititionition]

The data that exists is retrospective with many confounders. That's why the AANA is able to cloud the issue and make the claims they do ... the data is of poor quality, and the AANA's funding / publication bias is a thumb on the scale that is used to deliberately muddy things further.

There's no way a well designed prospective, randomized trial would get past an IRB, much less the consent process. How do you get a patient to agree to "nurse anesthesia with no help or backup from a doctor" rather than "physician anesthesia"? No person would agree to that, if given a choice free of pressure and economic influence.

To say nothing of the ethical problems with randomizing complex patients to what you believe is inferior care, and then being willing to let the CRNA hang alone, no matter what happens, just to prove it.

The study will never be done.

Agreed. But the study that COULD be done is to simply ask the patients the question AS IF they were being randomized... and then deliver care as usual (CRNA with physician backup/oversight).

You'd at least have a (probably overwhelming) patient preference number to use in these discussions...

 

[Planktonmd]

You know, I think we are all dancing around the same goal, but with different ideas on how to achieve it. The key is more involvement in care for the patient. That is what we need to get the ball rolling in order to earn more political capital. Meeting a patient 10 minutes before a surgery and acting like you are in a rush and then having the patient never see you again is not going to cut it. The PSH, while definitely a contrived idea of the ASA, is an idea that attempts to push anesthesiologists in the direction of being more involved in a patient's care. We NEED patients to know that we are thinking about their surgery and doing everything we are trained to do to get them through it safely. In our heads we know that we have created a safe anesthetic plan, but the patients need to know that as well...and preferably more than 10 minutes prior to the procedure. We need to show patients that CRNAs are under our direction and not just there in case something goes wrong.

We need increased visibility for both patients and for our surgical colleagues. That is what it all comes down to. If you have a better idea than the PSH then I am all ears.

Oh boy... too much Kool- aid!
All these things they are telling that you are going to do as part of the surgical home can easily be done by a CRNA or even by a nurse following protocols, So I am not sure how this is going to make you more respected as a specialist!
You want an idea better than this BS? here it comes: The ASA issues a practice advisory or a public statement stating clearly that anesthesia administered by a nurse anesthetist unsupervised by an Anesthesiologist is not endorsed by the ASA and considered sub-optimal for the patient. Very simple and very effective!

 

[Consigliere]

and even sent a letter to my internist suggesting a change in my blood pressure medications.

Dude, you need to stand upwind of your leaking Sevo vaporizer. NO ANESTHESIOLOGIST EVER will send a letter to an internist, who has probably known the pt. for 20 years, "suggesting a change in their BP meds." If I was an internist and ever received such a letter, this would be my reply:

"Dear Dr. Hard On:

Do not ever send me a letter recommending assinine changes in MY pt's BP regimen which we have been fine tuning over the past decade; stick to anesthesia.

Sincerely,
Dr. Internist"

 

[GravelRider]

Dude, you need to stand upwind of your leaking Sevo vaporizer. NO ANESTHESIOLOGIST EVER will send a letter to an internist, who has probably known the pt. for 20 years, "suggesting a change in their BP meds." If I was an internist and ever received such a letter, this would be my reply:

"Dear Dr. Hard On:

Do not ever send me a letter recommending assinine changes in MY pt's BP regimen which we have been fine tuning over the past decade; stick to anesthesia.

Sincerely,
Dr. Internist"

Thank you for making my point for me, fellow murse. We are not doctors and we are not viewed as being a doctor...even by our own colleagues in other specialties. Until we start acting like physicians and taking ownership of patients we will continue to be seen as expensive techs by other physicians.

Also, as an aside, the days of a patient knowing their internist for 20 years are becoming history. Most of the times the internist has such a large stable of patients that it would be almost impossible for him or her to know them as well as you suggest. Plus, it was probably an NP who saw the patient in question during the last 5 visits.

 

[Consigliere]

Thank you for making my point for me, fellow murse. We are not doctors and we are not viewed as being a doctor...even by our own colleagues in other specialties. Until we start acting like physicians and taking ownership of patients we will continue to be seen as expensive techs by other physicians.

Also, as an aside, the days of a patient knowing their internist for 20 years are becoming history. Most of the times the internist has such a large stable of patients that it would be almost impossible for him or her to know them as well as you suggest. Plus, it was probably an NP who saw the patient in question during the last 5 visits.

It is blatantly obvious that you have absolutely zero real world experience. I will no longer engage in discourse with you; we'll talk again when you get some hair on your nuts, CRNA.

 

[GravelRider]

It is blatantly obvious that you have absolutely zero real world experience. I will no longer engage in discourse with you; we'll talk again when you get some hair on your nuts, CRNA.

Hey nurse.

 

[Planktonmd]

Hey nurse.

He is simply trying to tell you his point of view based on his real world experience. You are certainly entitled to your own opinion based on your vast exposure to the specialty that obviously is beyond our comprehension, and hopefully you will prove us all wrong you and your ASA.
In my day when an attending told me something that I thought was not convincing I did not call him a nurse, did they change the rules???

 

[deleted171991]

S/he's right about one thing, though:

We are not doctors and we are not viewed as being a doctor...even by our own colleagues in other specialties. Until we start acting like physicians and taking ownership of patients we will continue to be seen as expensive techs by other physicians.

Yesterday I admitted to the ICU a patient who had had 5 OR anesthesia bodies (i.e. CRNAs and residents) taking care of him, during the 10 hours of neurosurgery. It's unforgivable. WTH is this, the telephone game? This shift mentality has to disappear.

There are already hospitals where complicated cases are followed by the same intensivist both in the OR and in the ICU. Those are viewed like real doctors, not just gas passers.

People who didn't go into a surgical or medical specialty, because they don't want to "own" patients, will have a very rude wake-up call come bundled payments and some form of PSH.

 

[pgg]

Yesterday I admitted to the ICU a patient who had had 5 OR anesthesia bodies (i.e. CRNAs and residents) taking care of him, during the 10 hours of neurosurgery. It's unforgivable.

Ridiculous.

I hate taking over cases about as much as I hate being relieved. I don't even like giving/receiving breaks, except for brief ones during long cases. It kills me when I make the OR schedule and have to waste 4 bodies on "breaks" ... I know the break people hate it too, and would rather be doing their own cases. But there'd be a mutiny if the 7:30 start time wasn't followed by an offer of a break at 8:something.

 

[GravelRider]

He is simply trying to tell you his point of view based on his real world experience. You are certainly entitled to your own opinion based on your vast exposure to the specialty that obviously is beyond our comprehension, and hopefully you will prove us all wrong you and your ASA.
In my day when an attending told me something that I thought was not convincing I did not call him a nurse, did they change the rules???

All those old-timers with their real world experience did a great job with this specialty. Thanks to them we are not fighting a turf battle with nurses and trying to maintain our status as physicians within the healthcare system. Great job guys. Thanks, but no thanks.

I am not a resident. It's time to relax with the "I'm an attending and because I say so" mentality.

 

[GravelRider]

... we'll talk again when you get some hair on your nuts, CRNA.

Oh...and he started it.

 

[Planktonmd]

All those old-timers with their real world experience did a great job with this specialty. Thanks to them we are not fighting a turf battle with nurses and trying to maintain our status as physicians within the healthcare system. Great job guys. Thanks, but no thanks.

I am not a resident. It's time to relax with the "I'm an attending and because I say so" mentality.

The specialty is in the state it is in because your leaders in the ASA conceded that a CRNA can be supervised by a physician... any physician and not necessarily an anesthesiologist many years ago, that's the biggest mistake in the history of this specialty and now they are pretending to solve the problem they created by completely abandoning intra-op patient care and becoming some kind of mutant hospitalists.
And if you are really not a resident and actually a practicing anesthesiologist then this is even worse! If you really believe this crap despite being in the real world then you are just beyond repair!

 

[Consigliere]

Hey nurse.

Good luck. Looks like you're gonna need it.

 

[Consigliere]

I am not a resident. It's time to relax with the "I'm an attending and because I say so" mentality.

Oh brother. You're a med student!? Even more clueless.

 

[Carbocation1]

http://www.fox26houston.com/news/45214539-story

 

[Carbocation1]

I like the comparison to flight attendant to CRNA comparison. This is what the public needs to hear.

 

[criticalelement]

+

http://www.fox26houston.com/news/45214539-story

Nurses expect it to start next year at the VA? is that true?

 

[Baller MD]

+

Nurses expect it to start next year at the VA? is that true?

That would be insane if it were to come to fruition.

 

[jl lin]

Oh boy... too much Kool- aid!
All these things they are telling that you are going to do as part of the surgical home can easily be done by a CRNA or even by a nurse following protocols, So I am not sure how this is going to make you more respected as a specialist!
You want an idea better than this BS? here it comes: The ASA issues a practice advisory or a public statement stating clearly that anesthesia administered by a nurse anesthetist unsupervised by an Anesthesiologist is not endorsed by the ASA and considered sub-optimal for the patient. Very simple and very effective!

Sorry. This thread is on the depressing side of things, but I think that's a great idea. The thing is, you have to get that message to the general public--the actual people undergoing anesthesia or who may be or of who have loved ones in need of anesthesia. I am a CCRN, and in truth I totally agree with you. People have to get out there. They have to be willing to talk with families, go on talk shows, whatever it takes. It's entirely unfair to the patients. There are many things that are unfair to patients--like discharging them to crappy rehabs w/ nurses or staffers that haven't a clue what things to watch and evaluate post-op patients for in the first place. Hell, you don't even know if these patients are getting their LMW Heparin day 2 post-op in these rehabs/nursing homes. Then the patients crumble or die, and no one wants to pay for an autopsy. And in fact an autopsy isn't really the issue, it's just helpful to demonstrate the lack of care and f/u for many patients. Patients are screwed if they don't have great insurance or someone w/ some decent knowledge watching over them w/ vigilance. All people should get excellent care, but that's not the reality; but hell, at least we are getting everyone "covered," supposedly. Anyway, sorry I digress.

My main point is that this issue needs to be presented in a compelling manner, repeatedly, to the general public. It requires a full-out campaign. Bitching about it doesn't change anything unless people do the work of change agents. Understand the stakeholders include the patients/general public.

 

[TeslaCoil]

+

Nurses expect it to start next year at the VA? is that true?

Before we know it plumbers will be pushing for independent surgical practice. They better get started protecting their interests now...

 

[jl lin]

Before we know it plumbers will be pushing for independent surgical practce. They better get started protecting their interests now...

And once again, the veterans get the crappy end of the stick.

 

[TeslaCoil]

Sorry. This thread is on the depressing side of things, but I think that's a great idea. The thing is, you have to get that message to the general public--the actual people undergoing anesthesia or who may be or of who have loved ones in need of anesthesia. I am a CCRN, and in truth I totally agree with you. People have to get out there. They have to be willing to talk with families, go on talk shows, whatever it takes. It's entirely unfair to the patients. There are many things that are unfair to patients--like discharging them to crappy rehabs w/ nurses or staffers that haven't a clue what things to watch and evaluate post-op patients for in the first place. Hell, you don't even know if these patients are getting their LMW Heparin day 2 post-op in these rehabs/nursing homes. Then the patients crumble or die, and no one wants to pay for an autopsy. And in fact an autopsy isn't really the issue, it's just helpful to demonstrate the lack of care and f/u for many patients. Patients are screwed if they don't have great insurance or someone w/ some decent knowledge watching over them w/ vigilance. All people should get excellent care, but that's not the reality; but hell, at least we are getting everyone "covered," supposedly. Anyway, sorry I digress.

My main point is that this issue needs to be presented in a compelling manner, repeatedly, to the general public. It requires a full-out campaign. Bitching about it doesn't change anything unless people do the work of change agents. Understand the stakeholders include the patients/general public.

YES! And this is exactly what im saying! What can we do? How can we take charge? Where do we begin?

 

[jl lin]

You get media interested, and you intelligently bring the concerns before the public.

If nursing can do this, why can't physicians? Answer: They can.

 

[TeslaCoil]

Ok! Lets do it! What should we say? How should we state our case? Support our claims?

 

[jl lin]

First, there will always be some resistance. You have to make your case in the best possible way that resonants with the people, who have been or will be patients. Personally, if I were to argue this, I would begin with making an argument regarding the fair number of patients that have serious comorbid issues, and what may well be required to provide best practices for them. This is indeed a serious issue. You have to have the right mental and experiential and critical thinking tools to be able to safely and effectively provide best practices to these patients. Look at the rising issue of obesity and early onset type II DM. I mean that is only scratching the surface.

Adversarial forces will throw out arguments that are really based on saving money; but complicated cases that go awry aren't necessarily money savers, but become more expensive each extra day that must spend in an ICU.

 

[Spinach Dip]

"This bickering is pointless." -Governor Tarkin

 

[TeslaCoil]

Heres how I see it, we film a commercial, all you see is a black screen but you hear audio in the background. Its an OR. You hear the beeping of the EKG monitor, and the clamoring of surgeons in the background. Suddenly, all you hear is a flatline... and then you see text: "If this was you or your loved one on the table, who would you want overseeing your care? A doctor or an advanced practice nurse?" and provide a link to more information. You don't think that would stir enough controversy?

Also, I personally know several high profile journalists who write for high profile publications, I'm more than happy to contact them with a plan for exposing these issues, but I'm not sure I'm qualified (nor do I think any one person is qualified) to get the job done with complete efficacy. I am more than willing to do the leg work and prepare a composite piece with input from multiple experienced physicians who are willing to speak about these issues. It would probably need extensive editing from experienced anesthesiologists in the field today as well. Does this sound like a sure step in the right direction? Just a big fan of taking action, and I think inaction on the part of the physician is partly what led to the field as we know it today.

 

[TeslaCoil]

"This bickering is pointless." -Governor Tarkin

Nice. Tarkin would just have every CRNA killed in their sleep. No bickering necessary.

 

[Spinach Dip]

Just a big fan of taking action, and I think inaction on the part of the physician is partly what led to the field as we know it today.

The CRNA issue reminds me a lot of what is going on in the middle east with ISIS/the refugee crisis/et al. Everyone thinks its horrible and really wants to see something done.... but no one is willing to step up and actually do it. And years later someone like Russia comes around and says "I'll take care of it!" And everyone else panics and questions their motives but still doesn't want to get their hands dirty and do anything about it.

Seriously this is a battle which shouldn't even be happening. If you give patients or surgeons the (informed) choice, they'd pick MDs over CRNAs something like 99% of the time. The only people who think CRNAs are an acceptable replacement are administrators looking to cut costs and the CRNAs themselves. Yet somehow MDs are losing this fight. Why?

Because they never even showed up.

Seriously you guys need to take Public Policy In The Internet Age 101. Websites, hashtags, facebook, youtube, google... this is how you get your message to the masses these days (without spending $10M on superbowl ads). As an example, when I typed "what is the difference between CRNAs and anesthesiologists?" into google a year ago, the top 10 results were all AANA propaganda sites about how CRNAs are just as competent and safe as anesthesiologists (if not more so).

So if you want to fight back and "preserve the future" of the specialty, the first thing you need to do is decide that it has a future worth preserving.

 

[Spinach Dip]

Nice. Tarkin would just have every CRNA killed in their sleep. No bickering necessary.

I was referring to the "If you haven't been an attending for 23 years you must ask permission to speak to me (and even then you will be wrong)" sort of bickering that frequents these boards.

 

[pgg]

All those old-timers with their real world experience did a great job with this specialty.

Great job? They made scads of money, practicing a supremely cool medical specialty, for many years. As jobs go, that sounds pretty great.

Seriously this is a battle which shouldn't even be happening. If you give patients or surgeons the (informed) choice, they'd pick MDs over CRNAs something like 99% of the time. The only people who think CRNAs are an acceptable replacement are administrators looking to cut costs and the CRNAs themselves. Yet somehow MDs are losing this fight. Why?

Because they never even showed up.

That's the wrong interpretation. They showed up, conjured a supervise-multiple-CRNAs model, and made truckloads of money on it.

There wasn't a fight; they sold out deliberately. And if I'd been there, I can't say I wouldn't have sold out either.

 

[TeslaCoil]

Great job? They made scads of money, practicing a supremely cool medical specialty, for many years. As jobs go, that sounds pretty great.



That's the wrong interpretation. They showed up, conjured a supervise-multiple-CRNAs model, and made truckloads of money on it.

There wasn't a fight; they sold out deliberately. And if I'd been there, I can't say I wouldn't have sold out either.

Its ok to sell out so long as you aren't totally screwing your own kind. And if you do sell out, it still warrants some checks an balances to keep what is happening in the field now from ever occurring. I can say I would have been more diligent. Or at least I would have tried. But that's not the discussion we're having. Its how to we fix it now that the sh itstorm is approaching. Have gotten some awesome responses on how to take the message to the public and to start turning this ship around, and that's exactly the sort of spirit that I created this thread for. Please keep those productive comments coming.

 

[Random Anesthesiologist]

S/he's right about one thing, though:

Yesterday I admitted to the ICU a patient who had had 5 OR anesthesia bodies (i.e. CRNAs and residents) taking care of him, during the 10 hours of neurosurgery. It's unforgivable. WTH is this, the telephone game? This shift mentality has to disappear.

There are already hospitals where complicated cases are followed by the same intensivist both in the OR and in the ICU. Those are viewed like real doctors, not just gas passers.

People who didn't go into a surgical or medical specialty, because they don't want to "own" patients, will have a very rude wake-up call come bundled payments and some form of PSH.

Agree. Finish your room, go home. Unless you have call/late duties.

 

[TeslaCoil]

Here is my question: Is a nurse qualified to assess the need for and deliver life saving measures in the event one might be needed in the OR? I'm inclined to say no. And so is everyone that I have spoken to about this. If not then we need to formulate a solid statement to give to lawmakers. Something along the lines of: "nurses are not qualified to practice independent of physicians because when life threatening situations arise, nurses are not qualified to assess the need for and deliver life saving measures." and then list the reasons why they aren't qualified. Again, its not in your average case where having a physician running it vs having a nurse running it will lead to better outcomes; its specifically in cases where things go awry.

Also, how does everyone feel about starting a physicians-only political group? Similar to the AANA, but for physicians? I feel as though a major component in this problem has been silence on the part of the physician, all while the nurses have been highly aggressive in the political arena. The ASA is active, but it isn't a physician-only group, so I feel as though the message becomes mottled.

I don't think physician anesthesia is far gone. It is threatened, and will continue to be so long as physicians are complacent, lazy and silent. I for one intend to take action. Would love to get as many others involved as possible.

 

[Carbocation1]

The problem is that crnas can do most procedures that are under the jurisdiction of the medical specialty. You can talk about how much physiology and pharmacology you know until you're blue in the face, but the bottom line is what tangible skill set do you offer that advanced nurses don't, especially with the assistance of Dr. Google? Can you take out the appendix? Can you stent the artery? This what hospital admins care about.

 

[Carbocation1]

I wish I liked surgery better, but I don't, so anesthesia is the next best option imo. Picking internal medicine, family practice, pediatrics, etc. is like choosing to be an english or anthropology major under the recommendation of your undergraduate academic adviser who has limited real life experience.

 

[TeslaCoil]

The problem is that crnas can do most procedures that are under the jurisdiction of the medical specialty. You can talk about how much physiology and pharmacology you know until you're blue in the face, but the bottom line is what tangible skill set do you offer that advanced nurses don't, especially with the assistance of Dr. Google? Can you take out the appendix? Can you stent the artery? This what hospital admins care about.

I somehow doubt that hospital admins don't care about patient outcomes. Especially, more specifically, sick and complicated patient outcomes. This is where docs are supposed to make the difference. There are plenty of procedures in anesthesia that CRNA's aren't qualified for. Its just a matter of docs speaking up about where to set the limitations.