What is the "militancy coeffecient" of your current practice?

[BuzzPhreed]

I'm interested in getting a sense of what your relationship is with the CRNAs at your current practice. In order to quantify what I've observed in the three places I've been since becoming a consulting Anesthesiologist, use the current scale - from 1 to 5 - based on the following criteria. Try to "average" them in aggregate based on these definitions and give us an overall feel for your practice:

1) Absent: The CRNAs all get along well with the physician staff, take direction appropriately, are willing to set aside their own preferences and adapt to doing the case the way the Anesthesiologist wishes, and generally go the extra mile to make sure things run smoothly. They don't attempt to do procedures, and they don't ask. They understand their role on the team as supportive and are there just to get the work done.

2) Low: Generally, these CRNAs will not question a treatment plan unless something doesn't make sense to them. They may or may not always call you, but usually consistently do when there is a problem. They are comfortable and interested doing some small procedures, but won't press it. Sometimes they may disagree with your plan, but are usually still deferential.

3) Moderate: In their own mind, these CRNAs have a solid idea about the "right" way to do a case, and feel like once you've gotten everything tee'd up for them, they probably don't need a lot of additional help. They will call you if they don't understand something... maybe. They also understand you need to be there for the TEFRA stuff, but won't stop and wait if you're unavailable. They also may change the pre-agreed treatment plan midstream without direction if what they're doing isn't working. They feel that CRNAs should generally be autonomous and shouldn't need a lot of help, but when they're lost they'll invariably seek it. They have an expectation that they should do some procedures and aren't reluctant to ask.

4) High: These CRNAs understand that Anesthesiologists are required by the hospital by-laws or state regulations, but they don't really think they need you. They want to do all the procedures for the patients under their care, and will only expect you to step in if they can't get it (and only after multiple attempts). They basically recognize that they need you for the regulatory parts of the job, and not much else. They frequently will change the plan, or not even seek input on the plan from you to begin with. After all, hey, they already know how to do this case. Why does it need to be discussed? They'll call when they are in deep ****, but not any sooner.

5) Full-on Militant: This group of CRNAs doesn't want physicians around. They have full support of the nursing staff and they often try to actively circumvent the Anesthesiologist whenever possible. The only time they will call for help is often when the crap has already splattered, and even then they expect you to only show-up, support what they're doing, not to actually take over, and just sign the chart. They don't really want you and, in their mind, they don't need you. You are nothing more than an obstacle to getting the case done, and they have no real clue why you even exist -- heck, they're already doing the case. "Get out of my way!" (Actually heard that once.) As an Anesthesiologist you are, at best, their equal and certainly not their superior.

Discuss.

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[BuzzPhreed]

The order of practices I've been involved with where:
first (academic) job - 3
first PP job - 2
"mistake" job - 3.5
return back to first PP job - still 2.

I like "2". I don't want complete doormats. Sometimes I like feedback and questions, especially from someone who's been doing it for 25+ years.

I think a large part of that is that I do about 70% solo in this job. Everyone knows we're competent. Everyone knows we can do a case. Everyone knows we don't just show-up and watch the CRNA do all the obvious and "visible" work. And they don't do any blocks (except the occasional L&D spinal and labor epidurals and maybe a lumbar epidural for a big gyn case and/or the a-line).

 

[Wiscoblue]

I think a lot depends on who writes their paycheck. We employ the CRNAs and hence they are a 2. At my academic job 15 years ago, they were closer to a 3.


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[BuzzPhreed]

I think a lot depends on who writes their paycheck. We employ the CRNAs and hence they are a 2. At my academic job 15 years ago, they were closer to a 3.

I think it depends more on the culture. The "mistake" job the practice employed the CRNAs and they were a solid 3.5 through-and-through. Most of the docs there were jellyfish. Of course that kind of happens when you're regularly a 4:1 ratio anyway. They become very independent because you otherwise can't do it all or be everywhere at the same time yourself. (And independent does not necessarily mean competent.)

 

[deleted171991]

What the definitions should contain, also, is the degree of support from your department: what happens to a CRNA who openly contradicts the anesthesiologist, doesn't follow instructions or does something stupid? If nothing, I would say that the practice is highly- to full-militant, especially if there are (unofficial) consequences for the anesthesiologist who brought the problem up in the first place.

 

[Mman]

solid 2. Out of about 100 CRNAs there are obviously variations, but everybody is a team player. If they weren't, we'd fire them.

 

[deleted126335]

First job was 3.5. Current job is a 2. Based on my experience it is a local cultural thing. Cultures take lots of time and effort and risk to change i.e., to go from a higher number to a lower number. Apathy and neglect and laziness are all that is needed for the culture to go from a lower number to a higher number.

 

[sevoflurane]

"0"

I don't work with them.

 

[Noyac]

No crna's here either.

 

[btbam]

#1 sounds almost as bad as #5.

 

[chocomorsel]

What the definitions should contain, also, is the degree of support from your department: what happens to a CRNA who openly contradicts the anesthesiologist, doesn't follow instructions or does something stupid? If nothing, I would say that the practice is highly- to full-militant, especially if there are (unofficial) consequences for the anesthesiologist who brought the problem up in the first place.

Exactly. The practice I am currently at, there is one CRNA who is militant and a total jerk. I am female, he is male. Already a problem. Then he is the boss's best friend. He can behave like a total ass and nothing happens to him because the boss always has his back. They are both dinguses and can't wait to leave.
And they are employed by the practice. The favoritism is disgusting.

 

[deleted171991]

Let's not forget that these militant CRNAs would not exist, especially in such large numbers, without all the dinguses who got rich by running CRNA farms, some by "supervising" cases while not even being in the building. That's why we have all the problems today: militant CRNAs who think they don't need supervision, 1:4+ coverage, TEFRA rules, independent practice for CRNAs, AMCs, you name it.

And as long as these dinguses are around, so will the militant CRNAs.

 

[sevoflurane]

Exactly. The practice I am currently at, there is one CRNA who is militant and a total jerk. I am female, he is male. Already a problem. Then he is the boss's best friend. He can behave like a total ass and nothing happens to him because the boss always has his back. They are both dinguses and can't wait to leave.
And they are employed by the practice. The favoritism is disgusting.

Hey there chocomorsel. I'm sorry to hear this. It is so frustrating. I worked with someone like that as a resident (only a handfull of interactions... but enough to leave a bad taste in my mouth). It was really deflating experience. I find it so incredibly important for anesthesia physicians to stick together in a cohesive and encouringing way. It benefits the entire group to have ea. others back like that. The type of issues you describe as a physcian post residency is really a reason to run for the hills... unless you deal with it infrequently... I guess.

I can't remember... are you also heading out west?

 

[deleted126335]

Let's not forget that these militant CRNAs would not exist, especially in such large numbers, without all the dinguses who got rich by running CRNA farms, some by "supervising" cases while not even being in the building. That's why we have all the crap today: militant CRNAs who think they don't need supervision, 1:4+ coverage, TEFRA rules, independent practice for CRNAs, AMCs, you name it.

And as long as these dinguses are around, so will the militant CRNAs.

I promise you, some of the young, incredibly talented and motivated, solid worker attendings that you know today are tomorrow's lazy entitled a$$holes. Granted they will have much less opportunity to rape and exploit. Saw people I thought the world of 25 years ago turn to ****.

 

[gasdoc1]

They are 2s where I work, with the exception of the "chief" CRNA. She runs the CRNA schedule for multiple sites for the anesthesia corporation, but she practices at my location. Sometimes I feel like she thinks that she ranks higher than all the docs. She is a decent administrator, but she is not very good, clinically. I often put her in her place, but I have been around as long as she has so she doesn't mess with me too much. Some of the younger anesthesiologists let her walk all over them.

 

[Planktonmd]

They are 2s where I work, with the exception of the "chief" CRNA. She runs the CRNA schedule for multiple sites for the anesthesia corporation, but she practices at my location. Sometimes I feel like she thinks that she ranks higher than all the docs. She is a decent administrator, but she is not very good, clinically. I often put her in her place, but I have been around as long as she has so she doesn't mess with me too much. Some of the younger anesthesiologists let her walk all over them.

Certain AMCs are empowering these "chief" CRNA's and intentionally giving them administrative authority over all the other employees including the physicians.
In their view these nurses are much easier to integrate in the corporate structure than physicians who tend to be opinionated and difficult at times.
This is the same reason why hospital administrators would rather deal with nurses than with physicians.

 

[RxBoy]

My current gig 1.5
Where I trained 4.5 (some sites were more like a 3).

As residents we simply didnt interact with them. They did their cases, we did ours. Of course we always got the best cases. They were hired by the hospital. My current gig, our group hires them.

Going from the 4.5 to the 1.5 atmosphere was a breath of fresh air. It took about a month for reality to set in when I was an attending.. I kept thinking there has to be some kind of catch to this work environment.

I dont miss doing my own cases as much as I miss train wreck cases. EVERYDAY was a thrill in training. I had the privilege of working with terrible surgeons and terrible patients,,, Probably the best training you can get. In private practive, its nice to be efficient but does tend to get boring. I can bang out 12-16 TKA in one day without a hiccup. In residency, it would of been 2-3 TKA for the day with near death to possible or death for all 3 of those cases.

I do moonlight and do my own cases but theyre usually outpatient b&b stuff (cataracts/endo/ect).

 

[BuzzPhreed]

Where I trained 4.5 (some sites were more like a 3).

Yeah, there were a few who were a full-on "5" where I trained. (That's where I heard the "get out of my way" comment... I was a CA-3 at the time too.)

It's interesting that the majority are "2" so far on the poll. I can surmise by this completely unscientific poll that most CRNAs like having us there, or at least understand their role on the team.

Maybe it's just that there's one (or a few) always one bad apple(s) that spoils the barrel. It's either the permissive, lazy, not up-to-date, incompetent anesthesiologist who spends more time in the lounge or the cafeteria than the OR and just lets the CRNAs do whatever they want, or it's some 50+ year-old ex-military nurse with a huge chip on his shoulder. Also why I think it's important to look at them in aggregate across the practice environment and try to keep perspective.

Either way, we need to do a better job of making sure the outliers are pulled better into the fold. It's hard for us as a group because too many of us are just too damn nice and laid back to speak up. And doctors (and nurses) aren't really formally trained on how to effectively manage people. Part of this is communicating clear expectations at the beginning of employment and then calling people out on their subsequent bad behavior.

 

[Hoya11]

in my gig i supervise, im the youngest guy by far. right out of training, good training, with skills at peak. i think this is what really puts the nurses in their places, is showing them that you literally dont need them for anything. New computer system throws off all the old-timers, so the nurses are relied on for charting. Sometimes they are relied on for getting and wasting drugs as certain attendings just dont know how to actually get narcs and return them and are afraid to try. And in reality I dont think their skills are actually relied on (ie all in my group can tube, due neuraxial, get alines/IVs ect, set up rooms), but I think that the nurses think the attendings can not due these on your own.

So I have had kind of a hands off approach intially when meeting a new CRNA, meaning that, Im not going to immediately PROVE that I can do these cases myself, Ill let you try your best, knowing that you WILL fail, and i WILL bail you out. So when we do cystos and basic cases we dont get into it about technical skills and nuances of management. At other times, when you start a liver/big belly case, and they miss the big IV and I get it, and they miss the Aline after 15 mins and I get it, and they try pathetically for an epidural (claimed they have done "many" of until i discover you are way off midline) then I get it right away - the CRNA starts to get the idea, and literally verbalized to me "im just slowing you down". So we go back in the room and I let her intubate (which usually happens), then prep the neck and throw in a central line. That is how i approach my day with all new CRNAs that I think will be potentially militant. Let them try, when they fail and see you bail them out OVER and OVER again easily, and then turn around and to the little things like fill in the chart correctly, take out narcs, set up your own room meticulously - they see the writing on the wall and your dynamic changes. We have to SHOW them our skills and knowledge for them to understand how the professional dynamic SHOULD be. Otherwise they generate their own opinions. Get involved in your cases, do little subtle things that improve outcomes that cookie cutter nurses arent thinking of. Do good nerve blocks, fast central lines, and be quick to take over at neuraxial. Put in your own IVs and alines in places where YOU want them and make sense for the case. Do your own charting and drug management. Be able to be totally independent, and show that off. Just chump them all day long clinically while being polite to them as a person, battle is over and the relationship is pleasant and professional.

 

[deleted126335]

ASAPAC started a new fiscal year on Oct 1

 

[Ignatius J]

Our is 0%. We don't work with cRNAs. We're physician only, and I love it.

Is it sustainable? That's a different topic for a different day. For the foreseeable future, absolutely. Our bottom line has never been better and business is rolling.

 

[chocomorsel]

Hey there chocomorsel. I'm sorry to hear this. It is so frustrating. I worked with someone like that as a resident (only a handfull of interactions... but enough to leave a bad taste in my mouth). It was really deflating experience. I find it so incredibly important for anesthesia physicians to stick together in a cohesive and encouringing way. It benefits the entire group to have ea. others back like that. The type of issues you describe as a physcian post residency is really a reason to run for the hills... unless you deal with it infrequently... I guess.

I can't remember... are you also heading out west?

Absolutely!!!!. To a Physician only practice!!!!. Can't wait. One more month.

 

[GA8314]

I think a lot depends on who writes their paycheck. We employ the CRNAs and hence they are a 2. At my academic job 15 years ago, they were closer to a 3.


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Agreed. As a resident, I observed a lot of 3's, and some 4's. In PP, where they are employees of our group, they are a 2.

And, like Mman said, anything more and we'd fire them.

I urge the CA3/Fellows out there looking for jobs to consider the CRNA culture, especially if you'll be in an ACT model with mostly supervision versus solo. The more dollars does not necessarily translate into better workplace quality of life for lots of reasons.

 

[GA8314]

Let's not forget that these militant CRNAs would not exist, especially in such large numbers, without all the dinguses who got rich by running CRNA farms, some by "supervising" cases while not even being in the building. That's why we have all the problems today: militant CRNAs who think they don't need supervision, 1:4+ coverage, TEFRA rules, independent practice for CRNAs, AMCs, you name it.

And as long as these dinguses are around, so will the militant CRNAs.

Yes indeed. I have heard horror stories about losers basically just signing charts. Unbelievable. And from credible sources. These f.ckers have done a lot of damage but frankly it's repairable. Every one of us can be more visible in the OR (ACT model). Can take a more hands on approach etc. etc. Each and every day we have opportunities which shouldn't be missed....

 

[Consigliere]

When the CRNAs were hospital employees - 3. Now that they are our employees - 1. Anyone 3 or above or who exhibits such behavior is fired.

 

[BuzzPhreed]

At one of the other area hospitals, if the anesthesiologist isn't immediately available at induction then they wait until he/she gets there before the case starts. Same with my hospital. Difference is at that hospital they run 3:1 or 4:1 frequently. We rarely are more than 2:1, and occassionally 3:1 - NEVER 4:1. Still, at the other place they wait. That's the culture.

At the job I left, this was not the case and the CRNA would often just induce, intubate, and by the time you got there the surgeon was already incising. I was almost always 4:1, and rare was the day that I was either less than that or solo (90% "direction").

Again I think it's about clear expectations about what's allowed. How you can bill for TEFRA "direction" in the latter is beyond me. And it breeds an equivalency mindset in many of them when 95% of the time (or more) nothing goes wrong. It's that pesky 5%.

Anesthesia Care "Team". What a bogus concept to many hubristic nurses. Reining that in? That's called leadership. I don't know if it's greed, apathy, or both that prevents some of us from being the leaders. Maybe some of these fatcats are just fooling themselves... or just don't care.

 

[deleted126335]

At one of the other area hospitals, if the anesthesiologist isn't immediately available at induction then they wait until he/she gets there before the case starts. Same with my hospital. Difference is at that hospital they run 3:1 or 4:1 frequently. We rarely are more than 2:1, and occassionally 3:1 - NEVER 4:1. Still, at the other place they wait. That's the culture.

At the job I left, this was not the case and the CRNA would often just induce, intubate, and by the time you got there the surgeon was already incising. I was almost always 4:1, and rare was the day that I was either less than that or solo (90% "direction").

Again I think it's about clear expectations about what's allowed. How you can bill for TEFRA "direction" in the latter is beyond me. And it breeds an equivalency mindset in many of them when 95% of the time (or more) nothing goes wrong. It's that pesky 5%.

Anesthesia Care "Team". What a bogus concept to many hubristic nurses. Reining that in? That's called leadership. I don't know if it's greed, apathy, or both that prevents some of us from being the leaders. Maybe some of these fatcats are just fooling themselves... or just don't care.

So why couldn't you fix it?

 

[Baller MD]

So why couldn't you fix it?

Because we need a collective effort?

 

[BuzzPhreed]

So why couldn't you fix it?

Oh, I tried. But I had no support. I was only seen as an "upstart" who was rocking the boat.

I was just one (of a few) dissenting doctor(s) among many who were quite happy with the way things are... until they lose their contract. So, I did the only thing I could. I left. It was a huge and extremely painful mistake. But staying would've been tacit endorsement of the way things were done there.

It requires a huge cultural shift in some organizations. And when the fatcat grayhairs at the top ain't interested, you only have one choice: vote with your feet.

It's hard to change things when you have zero support (either by lack of willingness to change, fear to change, or no empowerment to change). Life is too short. I went back to a job where I am appreciated, my opinions are sought and wanted, and the "man" ain't trying to keep me down and retrain me how to be a MDA, which is all that group really wanted.

I wasn't the only one who left that practice, by the way. Over a few years, they're ultimately going to only have spineless turds there as they continue to scratch their heads wondering why their outcomes suck.

 

[deleted171991]

One thing I learned is that, when a practice is hiring because somebody (especially a partner) left, there is dirt under the carpet.

 

[Ezekiel2517]

All MD/DO practice. We work hard but so much more gratifying doing your own cases. If you're a new grad I highly encourage doing your own cases as you start your career. If you think you are at your peak coming out of training, I laugh at you. You don't know what you don't know. You don't know your potential. I think I learned more in my first year as solo attending than all of residency

 

[Mman]

One thing I learned is that, when a practice is hiring because somebody (especially a partner) left, there is dirt under the carpet.

Not necessarily. There are lots of reasons people leave jobs. We've had a partner leave to move closer to family for help raising their young kids. We've had a partner leave because they were tired of working hard and wanted a no call job where they could have plenty of free time because they didn't need the money any more.

What's important is to find out why people have left. Any group that is on the up and up will be honest if you ask them about previous partners that have left.

 

[chmd]

All MD/DO practice. We work hard but so much more gratifying doing your own cases. If you're a new grad I highly encourage doing your own cases as you start your career. If you think you are at your peak coming out of training, I laugh at you. You don't know what you don't know. You don't know your potential. I think I learned more in my first year as solo attending than all of residency

It would be great to be in a stable all physician group for obvious reasons. But it is safer to join a group that has an efficient care team model. It'd stink to move to a new practice, have the model change and have to move on. Especially considering the rapid decline in reimbursement (for many people) and changing rules regarding insurance.

 

[Ignatius J]

It would be great to be in a stable all physician group for obvious reasons. But it is safer to join a group that has an efficient care team model. It'd stink to move to a new practice, have the model change and have to move on. Especially considering the rapid decline in reimbursement (for many people) and changing rules regarding insurance.

Don't know if I agree with this. We are a very large, very stabile physician only group. You would be surprised at how much can be done when fat cat founders and super partners build a group fairly and don't suck down all the revenue.

As for our group, we have flipped every insurance contract in the last year and our blended unit value continues to go up.

It's all leadership. Can't say enough about ours.

 

[BuzzPhreed]

Transparency = stability.

Leadership = success.

(Some "private practices" have forgotten this. They will feed you a load of bullsh*t. If you sniff it, run.)

 

[deleted126335]

Transparency = stability.

Leadership = success.

(Some "private practices" have forgotten this. They will feed you a load of bullsh*t. If you sniff it, run.)

They haven't forgotten. They just have no vision for anything beyond their own individual paychecks/retirement date.

 

[BuzzPhreed]

They haven't forgotten. They just have no vision for anything beyond their own individual paychecks/retirement date.

Very true. Maybe not "forgotten" but "myopic" instead.

I wonder if any of them ponder just exactly who is going to be taking care of them in a few years when they have their first major illness...

It's also about the legacy you leave.

 

[deleted171991]

Very true. Maybe not "forgotten" but "myopic" instead.

I wonder if any of them ponder just exactly who is going to be taking care of them in a few years when they have their first major illness...

It's also about the legacy you leave.

The "legacy" is in their bank accounts, and they are pretty happy with it.

In the end, that's the only thing that should matter to us, too. Anything else is just dust in the wind.

 

[Ignatius J]

The "legacy" is in their bank accounts, and they are pretty happy with it.

In the end, that's the only thing that should matter to us, too. Anything else is just dust in the wind.

I feel sorry for those who think the only thing that should matter is how much money you have. Speaking of dust in the wind....

 

[deleted171991]

You definitely misunderstood me. All I am saying is that I am unimpressed by whatever my employer says, unless they put their money where their mouth is. Talk is cheap. Today you're here and they sing your praises, tomorrow you're gone and they don't even know your name anymore.

I am not at all obsessed by money (a lot of you would not work for my academic salary), but I do care about my bank account. Why? Bigger account = increased security + earlier retirement.

 

[deleted171991]

Thank God income has nothing to do with happiness:

http://www.blog.greatzs.com/2014/11/how-much-money-does-it-take-to-buy.html

 

[Mman]

Thank God income has nothing to do with happiness:


http://www.blog.greatzs.com/2014/11/how-much-money-does-it-take-to-buy.html

Interesting study. Being poor definitely contributes to unhappiness because it's hard to meet basic needs. At some level of middle class income, your basic needs are obviously met, but you still don't have enough money to take care of things you might want to do or trips you might want to take so more money will open up the ability to do those things.

But I really don't think any amount of money buys happiness. Because mo money, mo problems. It's just different problems. I've lived life on $18,000 a year and been mostly happy and I've lived life on $800,000 a year and been mostly happy and at various points in between those extremes. But the more you make, you just have different worries. If I made $3M per year, I'd still have problems, they'd just be different problems than what I have now.

So in my experience, money can't buy happiness, but being poor can definitely help prevent you from being happy.

 

[deleted171991]

All those rich people and their many problems... They envy us soooo much!

 

[Wiscoblue]

If rather be rich and miserable than poor and miserable!

 

[Mman]

If rather be rich and miserable than poor and miserable!

Nobody has ever disagreed with that. But if you are poor and unhappy, winning a life changing amount of money in the lottery is unlikely to make you happy.

 

[deleted171991]

Nobody has ever disagreed with that. But if you are poor and unhappy, winning a life changing amount of money in the lottery is unlikely to make you happy.

That usually doesn't have to do with money per se, but with money management skills.

Lottery winners who choose the lump-sum cash payout tend to waste it within a few years, for the simple reason that most money-smart people don't buy lottery tickets in the first place (one has a higher chance of being struck by lightning than winning at the lottery). Then they wake up both poor and with no perspective for a decent job.

Now if I had $1M/year for 40 years, I doubt my happiness level would not improve by multiples.

 

[Mman]

Now if I had $1M/year for 40 years, I doubt my happiness level would not improve by multiples.

Wouldn't make a bit of difference to me. I'd live in a different house, drive a different car, and take different vacations, but I'd still be me.

 

[Consigliere]

Now if I had $1M/year for 40 years, I doubt my happiness level would not improve by multiples.

Whoa. Next time make it easier on us dumb folk and don't put in two negatives that then need to be translated into a positive. Too much thinking. For instance, the above bolded could have read:

I'd be happier.

 

[Mman]

Lottery winners who choose the lump-sum cash payout tend to waste it within a few years, for the simple reason that most money-smart people don't buy lottery tickets in the first place (one has a higher chance of being struck by lightning than winning at the lottery). Then they wake up both poor and with no perspective for a decent job.

Which I have to admit I find kind of ironic since the financially dumb move with a lottery payout is to take the annual payments.

But yes I agree that your average lottery ticket purchaser is not wise with money. I only buy lottery tickets when I think it becomes mathematically close to break even (as in expected jackpot is pushing $400+ million) and my odds of winning are probably in the neighborhood of what the after tax payout would be.

 

[deleted171991]

Whoa. Next time make it easier on us dumb folk and don't put in two negatives that then need to be translated into a positive. Too much thinking. For instance, the above bolded could have read:

I'd be happier.

Sorry. Dumb English as a third language speaker here.