I don't know how to describe this interaction. Arrogance? Hubris?

[BuzzPhreed]

So here is a not-too-long-ago interaction I had with a CRNA. This person is a PhD candidate, already has a DNAP, and had trained at Hopkins and had been in practice at Sloan-Kettering.

Here's basically how it went. It was a GA for a cysto with an LMA.

Her: "Hey I'm going to go do this case. I don't need you. Don't worry. I know my limitations. I'll call you if I have a problem."
Me: "Ummm... Okay. But I'm not going to sign your chart."
Her: "What?"
Me: "Find someone else to sign your chart."
Her: "Why not?"
Me: "Because that's called 'fraud' and I'm not going to do it."
Her: "Okay, whatever."

She did the case. Never called me. No one signed the chart. It came back to me later in a billing audit from the practice. I was expected to simply sign post hoc that I was there for the TEFRA portions. None of the partners got my back.

What would you have done? Needless to say this was at my prior job. No guesses as to why this is now my prior job, right?

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[deleted171991]

I would have reported her to the floor runner the very minute the conversation took place. That would have cleared up, in 5 minutes, on whose side the administration is (90% will be on the CRNA's side, but at least they will impose on her to respect the law).

I usually tell them to call me for induction, emergence and any problems, because it's not my preference, it's the law/rules. I even let them play doctor on their own, with me just being present there, as long as it's not a big deal.

These kind of jobs and CRNA attitudes will become the norm. The big problem here are the hospital administrators, who are nurses and love CRNAs; the minute you officially report problems with any nurses, even if you are 100% right, you become undesirable as a physician.

Btw, this is why we need unions in places like this.

 

[pgg]

What she did was wildly inappropriate, and possibly illegal - she should be crushed. Was she an employee of your group, or the hospital?

Ideally your group would agree and would take action. If not -

If what she did was legal in your state, I'd have reported her to hospital risk management because she violated the terms of her credentialing (which I assume required supervision/direction)?

If what she did was illegal in your state, I would have gone to the state nursing board with a formal complaint.

Last, there's always the media. Local news might've been interested in a juice story of unsupervised nurses and Medicare fraud.

And, if I was doing this myself because my group wasn't on board with ethics/safety, I'd have one foot out the door and be seeking alternate employment for myself.

I can see why you left.


Bottom line, either you're working someplace where the CRNAs need to be supervised/directed, or not. If the state laws require it, and she did a case solo after you told her you weren't going to be involved, she should be reported and sanctioned - no different than if a periop RN or housekeeper did the case.

 

[deleted171991]

What she did was wildly inappropriate, and possibly illegal - she should be crushed. Was she an employee of your group, or the hospital?

Ideally your group would agree and would take action. If not -

If what she did was legal in your state, I'd have reported her to hospital risk management because she violated the terms of her credentialing (which I assume required supervision/direction)?

If what she did was illegal in your state, I would have gone to the state nursing board with a formal complaint.

Last, there's always the media. Local news might've been interested in a juice story of unsupervised nurses and Medicare fraud.

And, if I was doing this myself because my group wasn't on board with ethics/safety, I'd have one foot out the door and be seeking alternate employment for myself.

I can see why you left.


Bottom line, either you're working someplace where the CRNAs need to be supervised/directed, or not. If the state laws require it, and she did a case solo after you told her you weren't going to be involved, she should be reported and sanctioned - no different than if a periop RN or housekeeper did the case.

All of these are two-way doors. The moment you report her or go against the group, expect to get reported yourself for other stuff. These people are experts in making you look like a "disruptive" physician.

In a situation like this, don't make waves, just find another job and leave. Don't burn bridges.

 

[pgg]

All of these are two-way doors. The moment you report her or go against the group, expect to get reported yourself for other stuff. These people are experts in making you look like a "disruptive" physician.

In a situation like this, don't make waves, just leave.

I'm squeaky clean, baby.

I'd retire off my winnings from the whistleblower retribution lawsuit.

 

[deleted171991]

I'm squeaky clean, baby.

Nobody is squeaky clean or perfect. You just don't know it yet. There are many ways to skin a cat. Any smart administrator will build up a personnel file against you, along the years, exactly for situations like this.

To get any money from a lawsuit, you have to prove damages. You don't get any money just for defamation.

Even if you are 100% clean (like most of us think we are), there is no use in turning people into your enemies. Pick your battles and make sure you have strong allies. History doesn't favor whistleblowers.

 

[urge]

So here is a not-too-long-ago interaction I had with a CRNA. This person is a PhD candidate, already has a DNAP, and had trained at Hopkins and had been in practice at Sloan-Kettering.

Here's basically how it went. It was a GA for a cysto with an LMA.

Her: "Hey I'm going to go do this case. I don't need you. Don't worry. I know my limitations. I'll call you if I have a problem."
Me: "Ummm... Okay. But I'm not going to sign your chart."
Her: "What?"
Me: "Find someone else to sign your chart."
Her: "Why not?"
Me: "Because that's called 'fraud' and I'm not going to do it."
Her: "Okay, whatever."

She did the case. Never called me. No one signed the chart. It came back to me later in a billing audit from the practice. I was expected to simply sign post hoc that I was there for the TEFRA portions. None of the partners got my back.

What would you have done? Needless to say this was at my prior job. No guesses as to why this is now my prior job, right?

Looks like the group was more interested in keeping her than keeping you.

I would have been more PC: "I still need to be present for induction and extubation. Call me when you are ready."

 

[drmwvr]

Sorry, but no sympathy here. She pee'd in one corner and it turned into a pissing contest as soon as you bit and said you'd not sign her record. Validating by answering tit for tat and then not showing up according to law or group culture is on you. She gave you a heads up she wouldn't be calling, which means specifically watching the board is obligatory.

Difficult people are everywhere. Learn how to handle them or risk being seen as a whiner.

 

[deleted171991]

I always love how partners call employees who don't take their crap "whiners". It's very easy not to be a "whiner", when you are making a (couple) thousand bucks on the case.

I especially disagree with this part:

She gave you a heads up she wouldn't be calling, which means specifically watching the board is obligatory.

Umm... NO! What's obligatory is for a CRNA not to induce without an attending being present in a medically directed case. There is no excuse for having done it in the situation described by the OP, and any responsible organization would have disciplined the CRNA in writing.

 

[pjl]

If you are necessary for induction, whether by law, supervision/direction rules, or local standard of practice, she should be standing thumb in butt waiting until you are present. No matter how much the patient or surgeon bitches. There is no other way to go about it, it is not like the patient will induce themselves if you aren't there within x amount of time.
She was clearly in the wrong, and should not have proceeded. Congratulations for doing the easy to say, difficult to do thing and not signing the chart, as well as leaving.

That said, you should have responded as urge said above, and been there promptly. A patient you presumably preop'ed that expects team model, deserves what they expected whether there is a political pissing match or not. I actually think this cases reflects worse on you than her. Could easily be spun as you "abandoning" your patient if something bad occurs. "So Dr., after preparing the patient for surgery, you refused to be involved in her care?"

 

[ScaleneDoc]

I've had this experience with these noctors before. It's cute. I simply tell them that my name is on the chart and hospital bylaws demand that I'm present for critical phases on the anesthetic. I used to have big pissing matches with them until I realized that if you wrestle with pigs, 2 things happen: they like it and you get dirty. Next time stay in the room and call all the shots. What is she going to do??..turn YOU in???

 

[BuzzPhreed]

I was paraphrasing slightly, but you guys got the gist. We had at first a relatively pleasant exchange about me needing to be there and for her to call me. After she the third or fourth scoff from her about how others allowed her to operate in that practice it turned into "well, I'm not going to sign your chart then". And I didn't.

I share this also because this is one of the games some of the "seasoned" and militant CRNAs will play with new hires, especially you guys fresh out of training, to see what they can get away with.

Bigger point is that this practice seemed to tolerate this a lot from her (and certain other) CRNAs there, some of them that were good and some of them that were marginal to terrible. I think you realize quickly when it's better not to pull out your Johnson and start pissing into to wind and instead just leave (which I did).

I probably could've made a ruckus but instead I just quit. And you're right, urge. They were likely more interested in keeping her.

In the end the chart came up for billing audit after I had resigned and was in my notice period. I won't disclose here what I did. I'll simply take the fifth.

 

[BuzzPhreed]

Next time stay in the room and call all the shots. What is she going to do??..turn YOU in???

Hard to do when in addition to her's you're directing three other rooms. You rely on communication. You rely on their professionalism. You rely on them telling you if there's a problem.

 

[pgg]

Nobody is squeaky clean or perfect. You just don't know it yet.

Could be. This is just one more reason to be an all-around nice guy. I get along with everybody. Admin would have their work cut out for them making a disgruntled/abusive/unprofessional paper trail on me.

You're right, history doesn't favor whistleblowers. I'd expect to need a new job. But you went down that road anyway ... so, maybe leave a turd on the doorstep before the door hits you on the way out?

 

[drmwvr]

[/QUOTE] Umm... NO! What's obligatory is for a CRNA not to induce without an attending being present in a medically directed case. There is no excuse for having done it in the situation described by the OP, and any responsible organization would have disciplined the CRNA in writing.[/QUOTE]

Don't agree at all... all the hand wringing and angst about crna's eating doctors lunches while administrators permissibly find something else to do and the answer is to hope the organization will act responsibly after the physician walks away from the fight? That speaks volumes, primarily that the physician is malleable and the crna is not. The outcome here was predictable and, if I may be so bold, not undeserved.

 

[deleted171991]

Don't agree at all... all the hand wringing and angst about crna's eating doctors lunches while administrators permissibly find something else to do and the answer is to hope the organization will act responsibly after the physician walks away from the fight? That speaks volumes, primarily that the physician is malleable and the crna is not. The outcome here was predictable and, if I may be so bold, not undeserved.

Did the CRNA call the MD for induction, as she was supposed to, and the MD didn't come? No. She decided not to call the MD and induce alone. There is no excuse for that, except in an emergency, but this was premeditated.

Should the MD have watched the board and jump when the patient was in the room, like a puppy? Still no, in my opinion. That's not his job. It's a nice courtesy, but that's not his job, with multiple rooms running. And he has the right to some dignity; either he is directing, or he's just a rubber stamp.

The only mistake was, in my opinion, that the MD did not immediately report the CRNA. I would have involved the floor runner right there, right then. No CRNA should be able to do whatever the heck she wants, politics or not. The floor runner is welcome to take over and sign for the billing without being in the room, if s/he believes in fraud for the sake of peace.

Now I imagine that the CRNA had been with the group for a much longer time than the MD, hence the nerve.

 

[deleted171991]

I probably could've made a ruckus but instead I just quit. And you're right, urge. They were likely more interested in keeping her.

I think you're wrong here. They were more interested in keeping and not pissing off all of the CRNAs. We anesthesiologists don't stand up for each other, but nurses do most things as a group. Plus there is more of them. In the end, of course we physicians are the ones (divided and) conquered.

Every time a crappy group takes the side of the CRNA, our standing in the hospital drops again. Because the hospital administrators hear about it, and stuff like this doesn't really happen in any other specialty.

 

[Spinach Dip]

Good to know that you aren't needed at all.



(Unless the patient begins to tank. Then everything is your fault.)

 

[scudrunner]

Should have asked her what her limitations are, since she "knows them." What a lame situation.

 

[Ipassgas]

I may or may not have had an issue like this, only without the announced premeditation.

We have separate places to initial on the record for showing TEFRA compliance. After having talked to the prime (theoretical) offender, I may or may not have gone to the boss and said TEFRA says . . . And to keep us all from getting in trouble for fraud, I'm only going to initial the parts I was there for. Then I possibly went off site for a week.

The hypothetical issues resolved.

 

[Mad Jack]

If it was a medicare patient, report her to CMS for billing fraud. It's what she committed, after all. Nothing straightens out a facility's practices life a good 'ol federal investigation of their billing and procedures.

 

[deleted171991]

If it was a medicare patient, report her to CMS for billing fraud. It's what she committed, after all. Nothing straightens out a facility's practices life a good 'ol federal investigation of their billing and procedures.

You don't bite the hand that feeds you. You just bark at it, if really necessary.

 

[Mad Jack]

You don't bite the hand that feeds you. You just bark at it, if really necessary.

I guess I'm just not cut out for anesthesia. I'd have gone nuclear on a CRNA that pulled that on me. What she did was straight up illegal and I'd report her to an authority that could provide some enforcement, rather than some impotent hospital nurse administrator. If you don't and just sign off on it under pressure, you've essentially just become an accessory to fraud and now your ass is on the line if an investigation ever occurs.

It's sad because I really thought that once it came time to apply for residency, anesthesia would be such a great field to go into for a great number of reasons. But I'm far too quick to go nuclear (above hospital administration and straight to governmental/legal channels) in the sorts of situations you guys have to deal with on a regular basis. I don't get how you guys just deal with this.

 

[IlDestriero]

We have bylaws, policies and maybe even laws in place to avoid these issues. You can too. That nurse would only make that mistake once. If you want solo style practice, you've come to the wrong place. They know that when they are hired and we still get a great deal of CRNA interest.

 

[Ipassgas]

I don't get how you guys just deal with this.

None of us like it. A casual mention of the government, to the right ear, usually solves it.

We do what we can. Generally, you have to go along to get along.

Everyone, in every field, has their own brand of BS to fight through on their way to doing the right thing. Doesn't matter if you work at Wal-Mart or a on ballistic missile submarine. Look at the idiot that ruined a $4 billion dollar boat because he wanted a day off -so he started a fire. I'm sure good people worked alongside that joker.

There is no field that avoids all of the bs of working with weak people and cumbersome systems. Especially not in medicine. Good luck finding utopia.

 

[Mad Jack]

None of us like it. A casual mention of the government, to the right ear, usually solves it.

We do what we can. Generally, you have to go along to get along.

Everyone, in every field, has their own brand of BS to fight through on their way to doing the right thing. Doesn't matter if you work at Wal-Mart or a on ballistic missile submarine. Look at the idiot that ruined a $4 billion dollar boat because he wanted a day off -so he started a fire. I'm sure good people worked alongside that joker.

There is no field that avoids all of the bs of working with weak people and cumbersome systems. Especially not in medicine. Good luck finding utopia.

It is more the degree and sort of BS you have to deal with in anesthesia, not the fact that there is BS to be dealt with. You don't deal with people trying to bill illegally under your name in psychiatry, with nurses trying to perform your operations in surgery, or with serving as liability sponge for a pile of midlevels in PM&R. Anesthesia really puts you at the crossroads of many of the worst aspects of the modern medical workplace, from midlevel encroachment to the disappearing of physician-owned practices to liability sponging to protect midlevels, hospitals, and AMCs at no benefit to yourself.

 

[BuzzPhreed]

I'm with you Mad Jack. I agree with a lot of what you're saying. The problem is that the system is so stacked against the little guy. Trust me. I've thought about qui tam'ing their asses. But as someone a lot smarter than myself once told me, "If you are hell bent to f*ck someone, be prepared for an equally painful retaliatory reaming."

I just left the practice. I've stayed in touch with some of the better people there and friends I've made. They keep me posted. I'm keenly watching developments there. I don't think they're going to be around as the current entity they are for much longer. And I will just feel bad for all the people who've been there 4, 5, 6+ years and still aren't partners. They're the ones that are going to truly get screwed.

 

[deleted171991]

“Before you embark on a journey of revenge, dig two graves.”

 

[BuzzPhreed]

The best revenge for me was leaving that practice, coming back to my previous job (where I was welcomed with open arms, am respected, and appropriately financially rewarded to the tune of close to six figures more of annual income than I was offered and getting at the false-partnership-promise sweatshop), and sitting back and watching while that practice goes down in flames... which I have on good authority is in the process of happening... imminently.

 

[IlDestriero]

If it is failing, this is the opportunity to go in and bid for their contract. One of my friends is an a successful group and their recent expansion has been taking over contracts from small places that went AMC and regretted it.
Your insider knowledge gives you a better bargaining position, and your relationship with former "partners" would set you up to recruit them into the new group. I believe you said it was a desirable location, so recruitment shouldn't be a big problem.
That's what Jet did. Take a chance and create the group you want to be a partner in.

 

[pgg]

Somehow I just have to believe there's a middle ground between biting the hand that feeds you while digging two graves for your revenge scheme ... and not being party to Medicare fraud while letting militant nurses break the law and violate hospital policies.

 

[deleted171991]

Of course there is. That's what I call "barking". But if nothing changes after you speak to your management, it's better to just walk away from the job.

If this kind of interaction went unpunished once, it will happen again. And again, and again. But you're just one, and you're an employee, so there is nothing to win by fighting the system, and a lot to lose. Don't forget that the US employment system puts a high value on recommendations from your previous workplaces, and you will never find out who did you a "favor".

 

[Mman]

at our practice she would have been fired for such an attitude. My medical direction of the case isn't optional for the CRNA regardless of how much they might feel like they can handle it just fine. Then again, CRNAs that work for us tend to self select out of having that attitude. We've got a great group.

 

[sevoflurane]

at our practice she would have been fired for such an attitude. My medical direction of the case isn't optional for the CRNA regardless of how much they might feel like they can handle it just fine. Then again, CRNAs that work for us tend to self select out of having that attitude. We've got a great group.

Working side by side is always the wrong move. Bringing them in under your umbrella is always the right move IF you are going to supervise.

 

[BuzzPhreed]

If it is failing, this is the opportunity to go in and bid for their contract. One of my friends is an a successful group and their recent expansion has been taking over contracts from small places that went AMC and regretted it.
Your insider knowledge gives you a better bargaining position, and your relationship with former "partners" would set you up to recruit them into the new group. I believe you said it was a desirable location, so recruitment shouldn't be a big problem.
That's what Jet did. Take a chance and create the group you want to be a partner in.

In the short time I was there I was well-liked by the surgeons and the ancillary staff. I think that entire practice needs an enema and a lot of people both inside the organization and on the periphery would agree with me. But I don't think they are going to lose the contract any time soon. I'm not even sure what their contract cycle is because I was of course never privy to that information.

I think what's going to happen - and just as I suspected shortly after I took the job there - is that they are going to sell out to an AMC. That's the rumor going around now.

If this kind of interaction went unpunished once, it will happen again. And again, and again.

More so, this was the actual culture at this group.

 

[BuzzPhreed]

at our practice she would have been fired for such an attitude. My medical direction of the case isn't optional for the CRNA regardless of how much they might feel like they can handle it just fine. Then again, CRNAs that work for us tend to self select out of having that attitude. We've got a great group.

None of the docs there had a spine. They were all lazy (except a few) who liked things just the way they were. Fat cats cashing in. Sign the charts. Collect the pay. Let the nurses do all the work. Many of the CRNAs even hated it and left. Some of them actually want direction from time to time believe it or not.

 

[sethco]

Holy crap, this thread is depressing. I can't tell you how nice it is to do your own cases. I trained side by side with both CRNAs and SRNAs and I can attest that my quality of life has been greatly improved over the past year!

 

[Mman]

Holy crap, this thread is depressing. I can't tell you how nice it is to do your own cases. I trained side by side with both CRNAs and SRNAs and I can attest that my quality of life has been greatly improved over the past year!

trained side by side doing what? They certainly aren't getting the education you should have been getting.

 

[michigangirl]

There's no question the CRNA sucks and has a big attitude problem, but I agree you (or anyone in this situation) should have reported her immediately if legally she needs an MD on the chart. It's fine for you to not sign the chart if she's not going to call you or involve you, but why should the patient get screwed? If something did go wrong, in this case noone advocated for the patient.

Plus, if something did go wrong, it's a game of he/she said he/she said, unless there is written documentation or witnesses of this exact conversation she could say she called you and you refused to be there, so many ways it could go. Why take the risk?

 

[jwk]

I'm reading through this whole thread - and maybe I just live a sheltered life, or maybe I'm just so used to working in a by-the-book TEFRA anesthesia care team practice that I don't get it. A CMS audit, leading to triple damages on each and every fraudulent bill, is PLENTY of incentive to do things the right way if one is billing medical direction. All seven items on that list of TEFRA requirements are met on each and every case we do. Our billing software picks up any time discrepancies, and those have to be resolved before we submit a bill. Our new EMR software prevents almost all time and ratio issues - an anesthetist can't sign in on more than one case at a time (people forgetting to sign in/out for breaks used to cause problems), and MD's can't mistakenly sign onto a 5th case at any one time because the software won't allow it.

To think that anesthesiologists and/or CRNA's are perfectly willing to ignore the TEFRA regs in a medically directed ACT practice just seems plain stupid. Even inadvertent mistakes can cost you, but deliberate billing fraud? Dumb, dumb, dumb. I'm not sure of the statute of limitations, but why would you want the risk of EVERY medicare billing record going back at least two years in your practice to be questioned?

As far as the original CRNA in question - they would have been fired on the spot in our group. Not at the end of the day, not between cases - we would have gotten another anesthetist or doc to do the case and they'd be out the door. I realize there are issues with hospital-employed CRNA's and private practice docs - but in a group where the docs employ the anesthetists putting up with crap like this? Really? It would never happen where I am - nor any of the many centers I'm familiar with across the southeast.

 

[BuzzPhreed]

[snip]... maybe I just live a sheltered life ...

You live a sheltered life.