Attendings & Residents: Take the pledge

IlDestriero said:

The problem that you're going to have with #1 is that, for those of us working in a care team system, the smarter and better trained your CRNAs are, the safer care you provide for YOUR patients. Something that you teach your CRNAs now can save YOU, and your patients, from disaster later. They're working on your insurance, your license, your reputation, and you can't always be there, so you want the best you can get. 2-8, sure. Not explaining my decision making to my CRNAs? Sorry, but no.
I don't train SRNAs, so that part is not an issue.

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flashgordon said:

Time to man up and take the pledge:

1. NEVER teach a CRNA or SRNA anything. If they ask "why/how did you do x/y/z", politely say "i dunno, just cause".

2. Do NOT allow them to do any Regional blocks. Maybe a spinal, but that's very generous. No ultrasound blocks or epidurals.

3. Do NOT allow them to do any Invasive lines. Maybe an arterial line, but that's generous.

4. STEP UP and take call or stay late if needed. Don't sell out our profession by being a "lounge lizard".

5. DONATE to the ASAPAC every year. Not just the minimum. Laws and policies are influenced by the amount of political donations.

6. EDUCATE your fellow attendings/residents/medical students. The more people know, the better.

7. EDUCATE your patient about your role as their Anesthesiology DOCTOR. Follow up on your patients post-op so they remember you.

8. WEAR your white coat when out of the OR. Why do you think all the surgeons do?

We can protect this awesome specialty from these POS militant nurses.

I, flashgordon, will take the pledge. Who's with me?




p.s. Feel free to print this out and put it in your wallet for easy reference!

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maceo said:

http://www.anesthesiaassistant.com/AnesthesiologistAssistantEducation.html

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flashgordon said:

"the smarter and better trained your CRNAs are"... the more they think they don't need you.

I understand your reasoning, however, this is a double-edged sword. Why do you think we are where we are today? The more you teach them, the more they slowly think they can do cases without you. I'm sure there's a way to explain your reasoning w/o actually teaching them?

And besides, why do you even have to teach them anything? Don't they learn everything they need to know to pratice independently in CRNA school?

I've seen attendings teach CRNAs/SRNAs in detail and give them articles to read, just like a resident. Where did a few of these CRNAs eventually end up? Practicing independently across town. Good job guys!!

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flashgordon said:

Time to man up and take the pledge:

1. NEVER teach a CRNA or SRNA anything. If they ask "why/how did you do x/y/z", politely say "i dunno, just cause".

2. Do NOT allow them to do any Regional blocks. Maybe a spinal, but that's very generous. No ultrasound blocks or epidurals.

3. Do NOT allow them to do any Invasive lines. Maybe an arterial line, but that's generous.

4. STEP UP and take call or stay late if needed. Don't sell out our profession by being a "lounge lizard".

5. DONATE to the ASAPAC every year. Not just the minimum. Laws and policies are influenced by the amount of political donations.

6. EDUCATE your fellow attendings/residents/medical students. The more people know, the better.

7. EDUCATE your patient about your role as their Anesthesiology DOCTOR. Follow up on your patients post-op so they remember you.

8. WEAR your white coat when out of the OR. Why do you think all the surgeons do?

We can protect this awesome specialty from these POS militant nurses.

I, flashgordon, will take the pledge. Who's with me?




p.s. Feel free to print this out and put it in your wallet for easy reference!

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aredoubleyou said:

Agree with the overall position. Someone will teach them procedures, even if you don't. I've seen it as a resident at an outside hospital, the lazy attendings would sit around and talk about cars while the crnas drop swans, place thorasic epidurals, regional blocks, etc. Discusting laziness. But what we can do is #4. Best way to differentiate ourselves from crnas is to get involved in the entire perioperative experience, work harder, stay later, become consultants not monkeys

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IlDestriero said:

Well, I provide the best care possible to my patients while protecting my own ass. My patient population is different from most, complex peds, so if I didn't teach them what to do and why, so that they can stay out of trouble in the future, they would be making bad decisions. Decisions that would have significant consequences, consequences that would cost ME my reputation, job, assets, and future employability. If you can figure our how to train them to make good decisions without "teaching" them anything, let me know. As was mentioned earlier, when your ass is on the line, you're only hurting yourself and your patients by keeping your CRNAs in the dark. It's easy to downplay that risk when you're still a resident. The buck doesn't stop at you yet. If they want to leave and try to open a complex peds practice across town, good luck, they'll need it. If they want to move to rural america and provide better care for peds patients, that's fine with me. I can't control what my employees do. But I can, and will, continue to make them the best physician extenders that they can be, it's in the best interest of all involved. If you feel so strongly about keeping CRNAs in the dark, find a group that is only direct provider care. Just be aware that these groups may have a limited future looking out 10 years.

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leaverus said:

My job is nearly perfect - i love it. I like the location; the surgeons and nursing staff are great to work with. The ONLY reason i'm thinking of leaving? CRNAs. Our anesthetists are "non-medically directed" so they are pretty much independent and we are token "supervisors." It is very difficult to work with people who truly believe they are my equals when it comes to patient care; they make their own decisions and any input on my part is met with resistance & resentment. I have no problem taking this oath. As for #1, do the floor/ICU docs explain the reasoning behind their decision-making to the RNs? While i agree that an uneducated CRNA is even more dangerous than an educated one, if a CRNA really runs into trouble they should be calling a doc rather than trying to manage on their own. That's really what they need to be educated on - how to recognize when they're in too deep.

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IlDestriero said:

If your not medically directing your CRNAs, what are you doing? If you're only there as a pre op line/block tech and a firefighter, I would not work there. It's not worth the risk.

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leaverus said:

No, i meant exactly what i wrote. We neither supervise nor direct our CRNAs. They are often doing their own pre-ops and cases from start to finish with no physician presence during induction nor emergence. They also do their own lines/blocks/whatever on their own prerogative. Docs meanwhile are often doing cases concurrently. Since i am not a partner, i have no say in this arrangement; and i don't know how the billing is done. Most of you guys probably have no idea what it's like working with people who expect to be treated as my professional equal.

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wine thief said:

please forgive my ignorance. are you in an opt-out state? is there an anesthesiologist of record?

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leaverus said:

Nope, not an opt-out state. There is an anesthesiologist of record - the "coordinator," who is often stretched far too thin to "supervise" in any meaningful way

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Mman said:

That is unfortunate and without knowing the details is borderline fraud. It also gives the rest of us folks actually supervising a bad name. I see all my patients in preop, am there for induction, periodically in the middle of the case, emergence, and again in the PACU.

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flashgordon said:

Time to man up and take the pledge:

1. NEVER teach a CRNA or SRNA anything. If they ask "why/how did you do x/y/z", politely say "i dunno, just cause".

2. Do NOT allow them to do any Regional blocks. Maybe a spinal, but that's very generous. No ultrasound blocks or epidurals.

3. Do NOT allow them to do any Invasive lines. Maybe an arterial line, but that's generous.

4. STEP UP and take call or stay late if needed. Don't sell out our profession by being a "lounge lizard".

5. DONATE to the ASAPAC every year. Not just the minimum. Laws and policies are influenced by the amount of political donations.

6. EDUCATE your fellow attendings/residents/medical students. The more people know, the better.

7. EDUCATE your patient about your role as their Anesthesiology DOCTOR. Follow up on your patients post-op so they remember you.

8. WEAR your white coat when out of the OR. Why do you think all the surgeons do?

We can protect this awesome specialty from these POS militant nurses.

I, flashgordon, will take the pledge. Who's with me?




p.s. Feel free to print this out and put it in your wallet for easy reference!

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flashgordon said:

Wow. Unfckingbelievable. Smells like fraud to me.

I don't think any of us has witnessed independent CRNA practice, let alone alongside MDs in the same group. Please tell us more...

1. How big is your group and who are the partners? Small
2. Major city or rural? Suburbs of major city. Small hospital.
3. Patient demographics? Low-middle class
4. Who does the daily scheduling/room assignments? Docs
5. What is the relationship with the surgeons like? How 'bout the hospital? Good.
6. Age and experience of CRNAs? Various
7. Are CRNAs doing only ASA 1/2 patients while MDs do the sicker ones? Not always.
8. How often are you curbside consulted or had to bail them out? Any deaths? Occasionally. No deaths, but couple of close calls.
9. Are the CRNAs taking call as well? Yes.
10. Are they billing independently? If so, why not just get rid of them & hire more MDs? Don't know this aspect of things.
11. How do they introduce themselves to the patients? Do patients ever ask "where is my anesthesia doctor?" Don't know. No.
12. How do the MDs co-exist with POS scum who think they are equal to you, demand to be paid the same, and have <10% of your knowledge and skills? I'm really the only one who is not CRNA-friendly, and that just boggles my mind.

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flashgordon said:

Wow. Unfckingbelievable. Smells like fraud to me.

I don't think any of us has witnessed independent CRNA practice, let alone alongside MDs in the same group. Please tell us more...

1. How big is your group and who are the partners?
2. Major city or rural?
3. Patient demographics?
4. Who does the daily scheduling/room assignments?
5. What is the relationship with the surgeons like? How 'bout the hospital?
6. Age and experience of CRNAs?
7. Are CRNAs doing only ASA 1/2 patients while MDs do the sicker ones?
8. How often are you curbside consulted or had to bail them out? Any deaths?
9. Are the CRNAs taking call as well?
10. Are they billing independently? If so, why not just get rid of them & hire more MDs?
11. How do they introduce themselves to the patients? Do patients ever ask "where is my anesthesia doctor?"
12. How do the MDs co-exist with POS scum who think they are equal to you, demand to be paid the same, and have <10% of your knowledge and skills?

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IlDestriero said:

If your not medically directing your CRNAs, what are you doing? If you're only there as a pre op line/block tech and a firefighter, I would not work there. It's not worth the risk.

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leaverus said:

Thanks for that info, alagory. It certainly answered my questions about how billing is probably done for my group.

If the CRNAs within a group such as mine do in fact bill at 100%, the only advantage this model would have over an MD-only group is that the former would be comprised of fewer docs and hence more money going to the partners.

I can tell you that i certainly hope such a model isn't becoming popular, because the inflated egos of the CRNAs in my group is unbearable. It's amazing how they (almost all of them) treat other nurses as if they're inferior. I've said it in another post and i'll say it again; the money isn't that important to me - i'd gladly work in a doc-only group for less money. So i don't "enjoy a much happier work place than any other practice."

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IlDestriero said:

The reason why the groups ask for these stipends for call, trauma call, etc is because they provide a service (covering call) which may not generate any income. Or provide a service to a low volume area, perhaps OB, where billing alone doesn't cover the cost of a 24/7 provider. It seems reasonable to me.
I find it hard to believe that an all CRNA group would not ask for the same/similar stipends if they were providing all these services in the place of the MDs. If they don't they're selling themselves short.
The AMCs may not ask for these, or ask less, because they make the money back in other ways, paying providers less for the same service, changing to a cheaper (for them) care team model, etc. It's a great way in the door, but when the honeymoon is over, they'll probably ask for more $$ as well.

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alagory said:

Just adding some information.

Many people do not understand what opt out is or what "medical direction" vs "supervision" is or how a CRNA can or cannot work "independently" in a non opt out state vs an opt out.

Seems it would not hurt to add some clarification to these confusing concepts. This explanation will not discuss separate hospital policies etc.

The terms "Medical Direction" and "supervision" are related only to CMS and medicare billing. They are not an indication of practice or a direction of practice of the CRNA by an MD. They are only relevant in CMS cases and were created by CMS (along with the 7 TEFRA rules) to enforce some degree of requirement on MDs who supervise/medically direct CRNAs and bill for their cases (up to 50% per case up to 4 rooms or ~6 units if supervising). This came along because of massive medicare fraud committed in the early 80s.

"Medical direction" is the only term that matters when the relationship is between CRNAs and Anesthesiologists. There cannot be 'medical direction' when a CRNA is not working with Anesthesiologists. This is a billing term which CMS uses for this relationship, it is not considered a dictation of scope of practice or control and CMS makes this very clear in the guidelines. In anycase an Anesthesiologist can bill 50 % of each case for up to 4 cases with a CRNA only if they meet the 7 TEFRA rules.

"Supervision" is also a billing term related to CMS only. Supervision exists when a CRNA is in a non- opt out state and is billing 100% of the CMS schedule. This is a COP (condition of participation) for the hospital to bill medicare part A for the anesthesia services. Regardless if the CRNA is working in an opt out or non opt out state they can always bill 100% of the CMS schedule as that is billed through medicare part B. Totally separate. The requirements for the hospital to meet the COP for medicare part A in non- opt out states is simply the need of the surgeon for anesthesia. That is it. There is no other requirement and the CMS guidelines are very vague to allow this to be so based on the needs of the hospital. There is no added liability for either the hospital or the surgeon who works with either an opt-out CRNA or non- opt out CRNA anymore than if they were working with an anesthesiologist. This has been discussed by the ASA legal counsel on multiple occasions and there is an article on the association website about it.

As the federal laws stand a CRNA can work independently in every state in the union and there is no requirement for anesthesiologist relationships.

What op-out does is relieve the hospitals from the need to meet the COPs for to bill medicare part A. This does not change anything from a practice perspective but does remove the word "supervision" from the language. While there has proven to be no increased liability with CRNAs working independently the fact is there remains perception that the word "supervision" implies liability. Sometimes perception is more important than reality and hence the reason why you see the ASA and AANA fighting over opt out which, essentially, has nothing to do with independent practice.... except for perception... Odd thing.

Now, as for the fraud issue. 2 points.

1) Any private insurance that is NOT CMS does not require any supervision or medical direction. However, they do generally pay CRNAs less per unit than they might pay Anesthesiologists. If it is a cash practice (like plastics) then the CRNA sets their own rates.

2) When a group of CRNAs and Anesthesiologists work for the same entity (be it a hospital or the same group) and the money all goes in the same pot, there is no requirement to meet ANY of the medical direction TEFRA rules for the Anesthesiologist. This is because the billing for the CRNAs is done as "QZ" (independent CRNA) and the MDs only bill for whatever they are doing (maybe blocks or consults or their own cases) so they do not have to meet any of the TEFRA rules since they are not billing 50% of each of the CRNAs cases. Remember, this is 100% about MDs meeting the rules in order to bill 50% of each CRNA room up to 4 rooms. This is the case regardless of opt out status.

So really the only time an Anesthesiologist must meet the "medical direction" 7 Tefra rules is when the CRNA and the Anesthesiologist are separately employed (say the CRNAs are hospital employees). This is true because the Anesthesiologist is now billing 50% of each of the 4 CMS cases they 'medically direct'. However, if the CRNAs were doing non-CMS cases none of this applies.

So reading Dr. leaverus posts it appears to me that the group is billing QZ for all the CRNAs (which is independent CRNA practice) and billing AA for the Anesthesiologist who is doing cases (which means anesthesia performed by the MD). This is absolutely legal and the Anesthesiologist carries no liability for the CRNAs working in the same department nor does the hospital or the surgeon.

This is quickly becoming a popular model across the USA as it allows al providers to generate RVUs and takes advantage of each ones expertise and skill set in a cooperative manner. Both providers in these settings make more money and enjoy a much happier work place than any other practice (including Solo Anesthesiologist or Solo CRNA).

As a side note, none of this can be done with AAs (or PAs if they were to work in anesthesia) as they are legally bound only to work in a 'medically directed' style model. Unfortunately this is not economically sustainable in the future and will likely mean less usage of AAs vs CRNAs who have considerably more flexibility in practice and therefore become more fiscally advantageous for both the anesthesia group or hospital that employes them.

I foresee the model Dr leaverus is working in becoming the predominant model over both ACT and all MD or all CRNA within this decade.

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BLADEMDA said:

I agree with most of your post but I have a few "clarifiers."


1. If the Anesthesiologist sees the patient and leaves the impression that he/she is invloved in the care of that patient then there IS Mediocolegal responsibility. The Surgeon, Nurses, CRNAS, etc. expect back-up and Anesthesiologist involvement in many of these types of practices.

2. When the Poop hits the fan I can guarantee you that surgeon and CRNA will expect the Anesthesiologist "supervisor" to be involved in the code or plan of action.

3. BY having less qualified providers doing more and more with less input means more PACU and intraoperative problems. There is no free lunch as CRNA does not equal Board Certified Anesthesiologist.

4. Supervision is pretty much non existent when MD to CRNA ratios surpass 1:6. Some may argue that ratio is more like 1:5 or even 1:4.

5. Any model which allows CRNAS to run around pretending to be a Doctor of Anesthesia without real, tangible Anesthesiologist back-up is a poor one.

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flashgordon said:

Leavrus- why are you still working there? Aren't you taking liability by stepping in or offering your advice/opinion to these nurses? 'Cause you know damn well they're excellent at recording things, so don't be surprised if your name shows up on their record. It's a good thing for the patients that you guys are there as a safety net.

I don't ever see MDs working alongside independent CRNAs as catching on. Even though there is not enough of us to go around, why even hire a CRNA when they bill medicare the same as an MD? If they don't want to work as a team, the let's expand the rights of AAs and go 1:4.

I'll prob get a TOS violation for saying this, but I stand by my wording: militant independent CRNA = POS scum. I have ZERO tolerance for fcking idiots who lack insight and believe themselves to be someone they're not. Every patient is someone's mother/child/sister and deserves a physician anesthesiologist involved during this critical moment in their life. Anyone who undermines this for the sake of money (independent CRNA) should be shot.

We (ASA & AANA) could have worked as a team to deliver the best care possible, but greed got the best of these nurses. I do have high hopes for the current generation of residents & med students, who are starting to become less tolerant of the AANA.

It's not too late to save this amazing specialty.

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alagory said:

Hello.

I think that everything you said here is entirely debatable and not related to actual practice but your personal feelings. Which is fine. It is simply important to delineate fact from opinion.

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maceo said:

the answer is staring us right in the face..... PHYSICIAN ASSISTANTS IN ANESTHESIA... EXPAND ANESTHESIOLOGIST ASSISTANTS TO GET LICENSED AND RECOGNIZED IN EVERY STATE IN THE US

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BLADEMDA said:

Here is a Quote from the "other" anesthesia forum:



"The fact is, this fits the legal description and would certainly be actionable. Regardless where those individuals are any place which does not allow SRNAs to do PNBs and other regional would be ACTIONABLE. I bet none of those hospitals would be willing to defend a lawsuit because their MDAs have a political axe to grind to protect their pocketbooks. It would be over before it was even started."

CRNA

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alagory said:

I do not see how this would help in any possible way. Lowering the bar will not help anyones cause. Moreover, the reality is they would still be shackled to the 1:4 ratio AAs will always be stuck to and that won't work in the future of this healthcare economy. Just not possible.

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We don't need AA's. Lowering the bar to undermine CRNA's as a political ploy is a bad idea. Doing so in order to stretch resources (increase efficiency/make more money) is a bad idea too; it undermines the ASA arguments regarding levels of skill required; nobody is fooled by the CRNA's claim of intellectual equivalence, and nobody is fooled by the claim of supervision making up for lesser skill of AA's either... It's the money. That's all that drives the system then; not quality.

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Gimlet said:

Lowering the bar? Talk about problems delineating fact and opinion...

No offense, but that sounds like a quote right out of the AANA playbook.

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alagory said:

Son, you do not seem to know much about your own profession.

This was written on an Anesthesiologist blog I have read for years, not by the AANA. You can read it here

For your convenience here is the quote:



Adding another layer of provider which is even less qualified (PAs) certainly will not be a better solution.

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alagory said:

Just adding some information.

As the federal laws stand a CRNA can work independently in every state in the union and there is no requirement for anesthesiologist relationships.

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flashgordon said:

Exactly. You don't have to sit there and teach them x/y/z like some of the damn attendings I see. Especially when they kiss up to you and make you feel oh sooo smart that you let them do whatever they want.

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alagory said:

Son, you do not seem to know much about your own profession.

This was written on an Anesthesiologist blog I have read for years, not by the AANA. You can read it here

For your convenience here is the quote:



Adding another layer of provider which is even less qualified (PAs) certainly will not be a better solution.

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BLADEMDA said:

Here is a Quote from the "other" anesthesia forum:



"The fact is, this fits the legal description and would certainly be actionable. Regardless where those individuals are any place which does not allow SRNAs to do PNBs and other regional would be ACTIONABLE. I bet none of those hospitals would be willing to defend a lawsuit because their MDAs have a political axe to grind to protect their pocketbooks. It would be over before it was even started."

CRNA

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