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ThinkFast007

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Hey guys-

friendly neighborhood future anesthesiologist here. I come as friend from the Anesthesiology forum. so no flaming 😀

Just curious. Are you all aware that CRNAs (ie nurses) run some cases ocassionally for you guys, instead of the Anesthesiologist? I think some of you all know that, others probably never even realized. But yes, it's true. It's very scary.

You guys should check out this forum called ALLNURSES.COM you'll find plenty of these 'CRNAs' flaming/taking smack about surgeons etc. I find it repulsive.

As a future physician, I think we can all relate that sometimes our egos get a little bit of us. Nevertheless, anesthesiologists and surgeons joking around with each other and calling each other names is one thing (a bunch of my closest friends are going into surgery we do it all the time). But when a nurse calls a surgeon (PHYSICIAN) something I think that's inexcusable and should be stopped.

Why do I bring this up? These guys (CRNAs) are quite politcally active, their lobbying group is just increasing in size. I think as responsible physicians, WE need to join together in mking sure these guys dont get out of hand. I know you guys have your probs with PAs stepping on your toes ocassionally too. Just wanted to raise this issue up with you guys. I think we can all agree if anyone of our mothers were having surgery, you'd want a doctor performing the anesthesia as oppossed to a nurse. Ultimately, I think if we docs (and future docs) work together, quality patient care can and will occur. Demand better care for your patients, DEMAND that at your hospitals/centers that doctors are the providers of anesthesia.

btw..the guy named NITECAP, and rn233123 on our forum is one of these 'militant' nurses that I'm talking about on here.
 
The CRNAs at my program are generally excellent (I'm a resident in a surgical field). The CRNA degree requires several years of training after obtaining the RN degree. In academic medical centers, they function in the same role as anesthesia residents under the supervision of an attending (i.e. attending is present for intubation and pokes his/her head in the room intermittently through the case). I don't know how much independence they have in private hospitals, or if they are allowed to run cases unsupervised by a physician.
To the OP- you need to get over the whole "nurses should respect the MD" thing. In the real world, we are all colleagues, and you will find that experienced nurses know a lot more about practical medicine than you do, particularly when you start residency.
 
Hi there,
Really, anyone who feels the need to "put down" any other profession in or out of medicine is unprofessional and immature. I have to wonder if these folks who have to make someone the "butt" of their jokes are having insecurity problems about their jobs and abilities. I treat everyone with respect and most of the time, I am treated with respect. If not, I just don't have the time to sweat the small stuff. There is just too much to do.

njbmd 🙂
 
"Inexcusable insubordination"??? What is this, the military?

I'm sure many/most of us are aware that "CRNAs run some cases occasionally." However, I don't find it scary. As forbin said, they receive extended training and function at the same level as residents in the OR. They're colleagues, not "subordinates." That kind of terminology, and the attitudes it reflects, is arrogant and inappropriate.

All the CRNAs with whom I've worked have been excellent. They've been sharp, knowledgeable, and great with patients. They've managed difficult intubations calmly and skillfully.

I don't know how to interpret "making sure these guys don't get out of hand." What are they going to do? Riot? As far as toe-stepping, I disagree with the general notion (I know the OP hasn't stipulated this, I'm just stating my opinion) that throwing up our hands and protesting is the proper reaction to someone doing our jobs - effectively - with different credentials. If someone has the skills and does the job properly, kudos to him. If it becomes an issue of job scarcity, then we need strive toward standards for ourselves that increase our marketability and provide greater services to our patients.
 
A few years back, in my second internship year, I was doing my anesthesia month, and I was at the ambulatory surgery center (which is physically removed from the main hospital about 1/4 mile), and there are a lot of CRNA's there along with MDA's, and they are uniformly excellent - it's a machine with the surgeries moving along seamlessly. One of the CRNA's there, though, told me that he was a "Miller cripple" - had NEVER used a Mac, and didn't know/didn't care to know how to use it. Greatly in his defense, though, his one-trick pony did that trick consistently and without fail.

One other memory, though, was a trauma patient that I actually gowned for from the ED to roll her straight into the OR. I was holding inline stabilization and the patient was to be intubated (then I bail, they drape and cut just like that). I do not recall if the patient had been induced or not (because, now, retrospectively, I don't know why there was no cric pressure). The patient began to vomit, and the CRNA reflexively tried to turn the head (as I am holding inline stabilization). The trauma attending almost explodes right there, and the anesthesia attending asks the CRNA to 1. use the suction and 2. step back. The attending then steps in (as I am crouched down and to the left - the image you have is the goofy position I was in) and easily tubes this patient.

The point is, is that 95% of any job in medicine can be done by a monkey or machine (with the precision in the computer-guided wavemapper of the cornea, I think it's a no-brainer that, if not in this generation, the next will have an automated intubator that does its thing after humans have induced the patient - automated fiberoptic goes in and looks, scans the area, visualizes the cords, and passes the tube - hell, that's the deal with the video-assisted laryngoscopes and other intubating aids - the Karl Storz stylet, the Levitan, the fiberoptic - they all let you see the cords around the corner, instead of the manual need for a direct, inline view from the mouth to the cords), and it's only that 5% (that are randomly distributed) that need the specialist input, and that is the crux of the issue - how specialist do you need to be? As a comparision, let's talk about decubiti (lovely, eh?). I can do X amount, but, beyond that, I call GenSurg. However, they only go to Y, and I (more than once, but still rarely) have seen GenSx call OrthoSx because the decubitus was Stage IV and beyond them.

So, MOST anesthesia cases could be handled by a tech (and that means the MOST is the bread-and-butter, Mallampati grade I, ASA I, lap appy or MAC cases that are done nationwide on the assembly line), but have an underutilized MDA or CRNA and moves along without a hitch, and that's all well and good, and, when it becomes more intense, the MDA or CRNA moves up more to their level, and it's only in those much less common, technically challenging cases, where the question of MDA =?= heavily experienced CRNA. As another comparison, I remember a PA in vascular surgery who made a technically perfect anastomosis (with the vascular surgery attending there) in the OR, and there are the PA's that do the laparoscopic vein harvesting for CABG masterfully - the thing about the doing is the doing, and the more you do, the better you get.

I have no objection to midlevel providers (although, in my defense, I am NOT in the OR, and, if I never go back, even just to take a patient there, that's all right with me), and I only ask for the best person for the job - period.
 
Great post. 👍
 
Apollyon said:
As another comparison, I remember a PA in vascular surgery who made a technically perfect anastomosis (with the vascular surgery attending there) in the OR, and there are the PA's that do the laparoscopic vein harvesting for CABG masterfully - the thing about the doing is the doing, and the more you do, the better you get.
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Ok, I'm confused about that. I thought a PA was basically the same as an NP. Are you talking about a "first assist" here? Or is a first assist actually a PA? 😕



I'm just fine with CRNA's btw.
 
Are all of your 500+ posts just as bad? "Inexcusable insubordination"... please. I'm fairly sure that all surgical residents are aware of the presence of CRNA's.
 
All this talk of CRNA being lower, not being respectful, blah blah...it's just a smoke screen for the real issue. These future residents are afraid CRNA's are going to take their jobs and lower their salaries. You picked a specialty, deal with the drawbacks, go become a resident, and be good at what you do. The rest will take care of itself. Who cares what a CRNA is saying at some other website.
 
Sorry guys, should have specified mroe.

The concern is more that CRNAs are attempting to practice WITHOUT MD supervision. That is the great concern. In fact in several states that is already the case.

Would you really feel comfortable with a nurse administering anesthesia for say a Mallampati 4, with a ASA4? When your patients are sick as all heck? That's dangerous. There's a heck of a lot more to anesthesiology than just 'tubing and gasing'. I know as med students doing anesthesiology rotations, most of them were 'jokes'. Why? cuz usually, the attendings only assigned teh 'easy' cases to med students to watch,etc.

Personally, the infiltration of midlevels into medicine should be alarming to everyone. Look at what it's done to primary care. IF docs dont stick together on issues like this, who knows what the future holds. Managed care wants whatever is cheap, and helps their bottom line.
 
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ThinkFast007 said:
Sorry guys, should have specified mroe.

The concern is more that CRNAs are attempting to practice WITHOUT MD supervision. That is the great concern. In fact in several states that is already the case.
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I think they have to have MD (or DDS, DPM...) supervision, just not MDA supervision. (?)

And I see where that autonomy from an MDA can be a good thing for everyone, e.g., dental or GI procedures done in-office. My worry is MAC without even a CRNA present.

ThinkFast007 said:
Would you really feel comfortable with a nurse administering anesthesia for say a Mallampati 4, with a ASA4? When your patients are sick as all heck? That's dangerous.
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I wonder who would hire just any CRNA for that, though, Think. It seems the surgeon or hospital would make sure the CRNA had proved their competence before taking such a risk.

I would hope that experience and track record be taken into account more so than the degree.
 
FACS said:
Ok, I'm confused about that. I thought a PA was basically the same as an NP. Are you talking about a "first assist" here? Or is a first assist actually a PA? 😕



I'm just fine with CRNA's btw.
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Yeah, first assist - the attending vascular surgeon was right there, and the PA did the anastomosis.

Your question is not clear - the PA was not providing the anesthesia (that was a resident), but doing the procedure.

The "first assistant" can be anyone licensed/in training, up to the chairman of surgery (I've seen it).
 
During an anesthesiology rotation in med school, the Chairman of Anesthesiology once said (when asked about the CRNA/MDA issue)..."there are Anesthesiologists who are better than CRNAs, and there are CRNAs who are better than some Anesthesiologists"... 😕
 
ThinkFast007 said:
Sorry guys, should have specified mroe.The concern is more that CRNAs are attempting to practice WITHOUT MD supervision. That is the great concern. In fact in several states that is already the case.
No my friend, that is not the main concern. As you have alluded to in the anesthesiology forum, the concern is the prospect of making enough money because of increased take over of jobs by CRNA. Let's cut through the smoke screen and be honest here.

Compensation is a bigger issue with surgeons and surgeons to be here, because the profession has already felt the strain from reduced reimbursement. Personally, I think anesthesiologists making more money than surgeons is ridiculous and unfair. But, that's what we have these days.

I think it's good that physicians stick up for themselves and fight for their rights. But, let's be honest about why we're doing it. It's because of monetary concerns, not much else.
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MissMuffet said:
Again, anectdotal, but I really think there's something there... maybe the nursing model makes people kinder to pts than the medical model? (Not that I haven't had a few b1tchy nurses)
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With my n= ~5, the RN's that were going CRNA were doing as little RN work as was necessary and no more.
 
My experience w/ observing CRNA's.....
1. Reading a magazine, IVF bag was empty, pressure was 80/40, she got behind real quick, had to call the attending in.

2. Eating ice cream.

3. Dozing off during a whipple. I know the procedure is excessively long....but, hello, patient care?

That's 3 experiences in one year, one resulting in near-complication. I'm wondering who would have been responsible in court if #1 would have gone bad.....surgeon or anesthesia? (seriously---wondering.)
 
LovelyRita said:
My experience w/ observing CRNA's.....
1. Reading a magazine, IVF bag was empty, pressure was 80/40, she got behind real quick, had to call the attending in.

2. Eating ice cream.

3. Dozing off during a whipple. I know the procedure is excessively long....but, hello, patient care?

That's 3 experiences in one year, one resulting in near-complication. I'm wondering who would have been responsible in court if #1 would have gone bad.....surgeon or anesthesia? (seriously---wondering.)
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see, that's why the Anesthesiologist is much more important. I think our comittment to patient care and what we are known for and passionate about, vigilance, is something which mk pt care a priority.

In terms of why do we need a doctor and not just a CRNA. isnt a surgeon just enough for administering anesthesia? I really dont think whoever said that would really want that when it's their mom on the table. Would ya? Remember back about 100yrs ago when nurses were doing this under the supervision of surgeons...guys the mortality rate assoc with anesthesia complications was nearly 50% ! Anesthesiology is a lot mroe complex nowaday than what it was 100 yrs ago.

I would find it extremely disturbing that a surgeon would want to supervise a CRNA. I meah heck, it's your license. But, hey we have diff roles. you guys went on 7 more years and know whatever it is you all do. We will be doing our time in residency in order to learn the art/medicine of Anesthesiology. We each have our roles. We each should work together, not against each other or even at each others throats. THe goal is the same.
 
bigtimesmally said:
ThinkFast007 said:
Sorry guys, should have specified mroe.The concern is more that CRNAs are attempting to practice WITHOUT MD supervision. That is the great concern. In fact in several states that is already the case.
No my friend, that is not the main concern. As you have alluded to in the anesthesiology forum, the concern is the prospect of making enough money because of increased take over of jobs by CRNA. Let's cut through the smoke screen and be honest here.

Compensation is a bigger issue with surgeons and surgeons to be here, because the profession has already felt the strain from reduced reimbursement. Personally, I think anesthesiologists making more money than surgeons is ridiculous and unfair. But, that's what we have these days.

I think it's good that physicians stick up for themselves and fight for their rights. But, let's be honest about why we're doing it. It's because of monetary concerns, not much else.
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I have heard this often and I understand your concern. I respect the amount of work and dedication it takes to be a surgeon. Although I am going into anesthesiology, I have done several surgery rotations and have a somewhat decent understanding of the work required of you.

I am also aware that some anesthesiologists earn more than surgeons and know that it sounds unfair to you. I do not have an explanation as to why that is, but think that the symbiotic relationship that these two specialties have, can be worked out so that surgeons enjoy fair compensation and we as anesthesiologists enjoy job security.

To surgeons, OR time = compensation. The more procedures you do, the better you will do monetarily. The more time you spend rounding in the SICU and non-OR related issues, the less you will make.

There's a big push by anesthesiology residency programs to increase the amount of ICU-trained anesthesiologist and hence increase its presence in the ICU arena. As you may be aware, many east coast hospitals have anesthesiologists co-managing the SICU along with surgeons. However, this trend is not popular in other areas of the country.

So based on that I have two questions:

1) Would you allow anesthesiology to do the patient management in the SICU to give you the opportunity to spend most of your day in the OR operating (more $$ for you)?
This would allow surgery to do what they like (which is operate) and anesthesiology to increase their presence in the SICU. At the same time, this would allow both specialties to control the pre, intra and post-op arenas in the hospital.

2) To make sure surgery and anesthesiologists continue that symbiotic relationship that characterizes both specialties, would you be willing to accept a cut from the anesthetic fee in exchange for your guarantee to use anesthesiologists or their groups exclusively in lieu of independent CRNAs?

I'd like to hear current and future surgeons' opinions on this.
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toughlife said:
1) Would you allow anesthesiology to do the patient management in the SICU to give you the opportunity to spend most of your day in the OR operating (more $$ for you)?
This would allow surgery to do what they like (which is operate) and anesthesiology to increase their presence in the SICU. At the same time, this would allow both specialties to control the pre, intra and post-op arenas in the hospital.

2) To make sure surgery and anesthesiologists continue that symbiotic relationship that characterizes both specialties, would you be willing to accept a cut from the anesthetic fee in exchange for your guarantee to use anesthesiologists or their groups exclusively in lieu of independent CRNAs?

I'd like to hear current and future surgeons' opinions on this.
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Actually you're not being very accurate as to a surgeon's compensation. A surgeon is reimbursed as to the procedure they performed. All time spent including preop and post op care is included in that reimbursement. So time spent in the OR is irrevelent, its the number of cases or, the type (as in a whipple or Cyto-reductive sugery+hyperthermic peritoneal perfusion).

Its interesting to note that several procedures that surgeon's perform in the SICU actually pay more than some elective cases. And the SICU procedures do not require preop/postop clinic time.

Any physician that wants to work in a Critical care unit needs to be trained in their management. Obviously different approaches/problems that appear in the NICU/MICU/PICU/SICU that need specialized training.

CRNAs are available to Anesthesia as physician extenders not as replacements. Thats all I have to say about that.

The idea of symbiosis is interesting but not actually true. It really is more like teamwork in my understanding. Everything in the sterile field - surgeon's responsibility, behind the sheet - Anesthesia. There needs to be good communication for this relationship to be effective. But anesthesia will NEVER be able to do pre/postop care. How can they - its not part of their training and they didn't perform the operation. If critical care becomes part of your training as an anesthesiologist great, it seems to me that surgeons are always willing to share patients that they didn't operate on. But on their own sick patients, surgeons are a trifle more attached to.

And as to the cut of the anesthesia fee? That already happens at outpatient surgery centers - 1 anesthesiologist several CRNAs. The owners of the center just contract the work out to a anesthesia practice.

I hope I didn't step on anyones toes, but anesthesia is an instrinsic part of the surgical team. Just supporting rather than leading. But without good support the patient never leaves the table.
 
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ThinkFast007 said:
Personally, the infiltration of midlevels into medicine should be alarming to everyone. Look at what it's done to primary care.
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Um...primary care doc here. What, exactly, are you talking about? Midlevels haven't "done" anything to primary care that affects what I do every day. I think a lot of people read posts like yours and just keep repeating it as if it were true. 🙄
 
I dunno about eating ice cream in the OR....but I've seen residents and attendings nod off during a case. I've also seen them reading and so engrossed in what they're reading that they stopped paying attention to what was going on with the patient.

I'm not sure what the "shock value" of this thread was supposed to be...I am VERY used to CRNAs, as are probably the vast majority of surgeons/surgery residents.
 
drpectin said:
Actually you're not being very accurate as to a surgeon's compensation. A surgeon is reimbursed as to the procedure they performed. All time spent including preop and post op care is included in that reimbursement. So time spent in the OR is irrevelent, its the number of cases or, the type (as in a whipple or Cyto-reductive sugery+hyperthermic peritoneal perfusion).

Its interesting to note that several procedures that surgeon's perform in the SICU actually pay more than some elective cases. And the SICU procedures do not require preop/postop clinic time.

Any physician that wants to work in a Critical care unit needs to be trained in their management. Obviously different approaches/problems that appear in the NICU/MICU/PICU/SICU that need specialized training.

CRNAs are available to Anesthesia as physician extenders not as replacements. Thats all I have to say about that.

The idea of symbiosis is interesting but not actually true. It really is more like teamwork in my understanding. Everything in the sterile field - surgeon's responsibility, behind the sheet - Anesthesia. There needs to be good communication for this relationship to be effective. But anesthesia will NEVER be able to do pre/postop care. How can they - its not part of their training and they didn't perform the operation. If critical care becomes part of your training as an anesthesiologist great, it seems to me that surgeons are always willing to share patients that they didn't operate on. But on their own sick patients, surgeons are a trifle more attached to.

And as to the cut of the anesthesia fee? That already happens at outpatient surgery centers - 1 anesthesiologist several CRNAs. The owners of the center just contract the work out to a anesthesia practice.

I hope I didn't step on anyones toes, but anesthesia is an instrinsic part of the surgical team. Just supporting rather than leading. But without good support the patient never leaves the table.
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Oh? I wouldn't be so sure bout that if i were you. Are you saying anesthesiology residents dont train in the ICU? Dont forget, anesthesiologists do pre-op evals, have pre-op clinics, and have the final say regarding pre-op clearance. the residents, surprise surprise, are involved with this as well. We also do medical internships (for the most part), so our medicine background may well be more solid that that of our surgical colleagues.

As for your comment that how would anesthesiologists be able to do post-op care since they didn't do the operation. . .I will counter with this: anesthesiologists are probably much more familiar with the patient's hemodynamic state, medications, and physiology during the surgery, which is probably a lot more important for post-op management. Even in cases of infection, i'd say the anesthesiologist would be just as, if not more, familiar with treatment of sepsis, pulmonology, ARDS, etc. The only case the anesthesiologist would be less apt to know would be in cases of hemorrhage from the wound or from the sites of anastomosis, or dehiscence, although imo any good anesthesiologist should know how the surgeries are done. As a future anesthesia resident, and as a student who enjoyed my surgical rotations, I know I'm fascinated by how the surgeries are done. You guys should know, i'll be watching over the curtain with much interest! 😀

So before u guys go on making more assumptions about what an anesthesiologist can and cant do, perhaps you should find out more what our training entails. Also it must be recognized that there is a spectrum of different interests and motivations among us anesthesiology folk. A good portion of us are in it for the acute care of critical patients, for the challenge that anesthesiology is, and because we loved most everything in med school. It's a great field, with much variety, and is probably the only one that involves every other medical field out there in some way. 👍

The first step to great teamwork is respecting each other's expertise. 👍


p.s. the US is prob one of the only countries where anesthesiologists are not THE perioperative care specialists (although this is changing now). In europe, all the anesthesiologists do ICU work, pre- AND post-op care. . .it's part of their job description.
 
To KentW- Well, that's what I've seen and heard. The way that managed care works nowadays, it's soo much easier to have one MD and 2 NPs working alongside you. It increases the amt of pts that you see in your office. That to me is infiltration. How is it that something that once was a doctors job, patient care, is becoming mroe and more done by midlevels? Would you want your MOM or DAD to be taken care by a physician or a NP when they were very sick? I know my choice. I dont have to tell you, but you know it's all about PMPM for you guys. You guys get a set PMPM and if you dotn see enough patients then there are the negative incentives,et al. But hey dont have to take my word for it. I have many family members who are primary care docs and have told me how they hate their work now and how low teh compensation is. Dude, are you aware that a nurse anesthesist mks close to 150k? 150k is what most primary care docs mk, unless of course they are in large, predominant group. Do you think that is fair? You went to med school, residency, etc and dedicated your life toward pt care, now some nurse comes up and takes that away from you. It's quite frustrating in my opinion.

To the Surgeons-
Listen guys, what TouhgLife and I are saying is that this grudge b/w surgeons and anesthesiologists doesnt need to exist. We need each other's services. I have seen first hand what a good anesthesiologist can do for a surgeon. A good anesthesiologist can mk your life easy by getting the case started for you, and having the patient properly relaxed, therby giving you the ability to do what you love--which is surgery.

See, perhaps there are a few anesthesiologists that mk more money, but that is certainly not the norm. My understanding about you all's compensation is that what takes away from your 'money making opportunities' is clinic time. From what I've gathered you guys mk money via doing procedures, just like we do. Clinic just slows you down.

As ToughLife also mentioned, I think it would be great if we worked side by side with you guys in the SICU. We're not talking about some regular Anesthesiologist, but we're talking about the guys trained in Critical Care (which is also a fellowship for us). I'm not sure if you guys ever been to Iowa Univ, but they have an excellent SICU (and I think Case West too) because anesthesiologists and surgeons work symbiotically. Think about it, who better to manage you guys' patients medically post operatively than the doctors managing them intraoperatively?

Doctors, I think the issue is this. We as physicians do a pretty poor job watching each others backs. Almost every specialty in medicine has midlevels trying to take over some turf (ENT--> have the OMFS, Anesthesiology-->CRNAs, Primary Care--->NPs and PAs, Opthomology-->Optometrists trying to do cataract surgeries, etc etc..). I think we all could agree that patient care is a privelege and it is something that we all went to med school, residency, and beyond for. We spent the good part of our 20's studying,etc while our counterparts either partied, or partied even more :laugh: (not to say that we didnt, but you all get my point).

I know for certain that surgeons are hurting in terms of their compensation, and I know that my colleagues in the Anesthesiology realm would back you guys up to get you the pay that you deserve. The bottom line though is hospitals are looking at THEIR bottom line as well. As managed care is becoming more and more prevalent, midlevels WILL be taking the place of doctors...unless we prevent it. The midlevel organizations are HUGE and have HUGE lobbying power. Doctors, if we collaborate we would have greater strength. In numbers we could get better leverage in negotiating better reimbursements, etc from managed care organizations. We all will be happy, and our patients will get the best care they deserve.

sorry about the huge post.
 
ThinkFast007 said:
every specialty in medicine has midlevels trying to take over some turf (ENT--> have the OMFS,
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since when is OMFS midlevel to ENT?
 
Thanks for the support Surgery, much appreciated that you at least call thinkfast out on true intentions and recognize that CRNA's are safe providers. The guy hasnt even set foot in the OR yet but has this huge uniformed clueless agenda.
 
The CRNA-Anesthesiology debate reminds me of the conflict in the Middle East, and the Israeli-Palestinean debate.

Long long time ago Anesthesia was the turf of Nurses, then the MDs took over, and now the Nurses want their turf back.

Long long time ago Jerusalem was the "turf" of the Jews, then the Muslims took over, and now the Jews want their "turf" back.

The surgeons are like the Christians....they stand by the Jew, but also stand by the Muslims...in other words...they do not want any enemies.

:idea:
 
Orginally posted by thinkfast future anesthesia resident:
Yo nurses, do you guys really think we're that dumb? that we can't see through you? I cant wait to step inside the OR with one of you guys one day. The interaction will likely be like this, "hey nurse, I'm Dr.XX, go empty that urine. oh when you're done, get me some coffee". I suppose you all do serve some purpose.

This just shows the maturity level and professionalism of this guy and how much garbage his posts are.
 
ThinkFast007 said:
To KentW- Well, that's what I've seen and heard.
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Then you're over-generalizing. Most FPs do not employ midlevels, and we're doing just fine without them, thank you very much. My colleagues who have chosen to work with midlevels apparently have their reasons, but it really depends on what kind of practice you want to have. To each their own.

I dont have to tell you, but you know it's all about PMPM for you guys. You guys get a set PMPM and if you dotn see enough patients then there are the negative incentives,et al.
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Not in my world. Believe it or not, there is life outside of capitated managed care; you don't have to work as a salaried slave to the big health systems unless you want to.
 
KentW said:
Not in my world. Believe it or not, there is life outside of capitated managed care; you don't have to work as a salaried slave to the big health systems unless you want to.
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absolutely, I am agreeing with you 100%. I for one, never really understand why docs gave into capitated managed care. In fact, managed care companies HATE it when docs dont join, and/or when they join multispecialty (large) groups.
 
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"Ok, I'm confused about that. I thought a PA was basically the same as an NP. Are you talking about a "first assist" here? Or is a first assist actually a PA?"

FACS: in reference to your post... PAs and NPs have similar responsibilities and function in similar settings. However, there are a few differences in their training and scope of practice. One of those areas is Surgery. PAs can Assist in Surgery (NPs cannot unless they are also RNFAs). There are other personnel that can First Assist (CST,CFA, SA-C, RNFA). In various regions and in different sub-specialties of the country the utilization of certain assistants vary. For instance in NY, PAs are utilized almost universally. In the south there are more Certified Surgical Techs (CST) or Certified First Assists (CFA) that do the "job". The ability of PAs to provide perioperative care is what sets them apart from the other assistants. That is why some surgeons utilize them as the preferred provider for their patients.

If you have more questions about PAs in Surgery feel free to PM me.
 
Thanks for the support guys! I am new to the message board world and am starting nurse anesthesia school in a few months. I came to this one seeking knowledge as everyone has something to add to the pot. I was initially agast at the anesthesia board until I realized that some of the antagonistic posters were med students and had yet to step into the real world. I know there are some crna students that like to feed the animals. I have been a RN for 13 years and always enjoyed professional and collegial relationships with physicians and surgeons both at work and outside of work. I'm glad to know that this will continue. I'm not out to take away work from anyone and there is plenty to go around, and yes your reimbursement suck. Thank you for your support and level-headedness and I look forward to working with you in the future.
 
bigtimesmally said:
ThinkFast007 said:
Sorry guys, should have specified mroe.The concern is more that CRNAs are attempting to practice WITHOUT MD supervision. That is the great concern. In fact in several states that is already the case.
No my friend, that is not the main concern. As you have alluded to in the anesthesiology forum, the concern is the prospect of making enough money because of increased take over of jobs by CRNA. Let's cut through the smoke screen and be honest here.

Compensation is a bigger issue with surgeons and surgeons to be here, because the profession has already felt the strain from reduced reimbursement. Personally, I think anesthesiologists making more money than surgeons is ridiculous and unfair. But, that's what we have these days.

I think it's good that physicians stick up for themselves and fight for their rights. But, let's be honest about why we're doing it. It's because of monetary concerns, not much else.
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And how do you feel about a CRNA making as much money as a surgeon?
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blocks said:
bigtimesmally said:
ThinkFast007 said:
Sorry guys, should have specified mroe.The concern is more that CRNAs are attempting to practice WITHOUT MD supervision. That is the great concern. In fact in several states that is already the case.



And how do you feel about a CRNA making as much money as a surgeon?
Click to expand...


Where are CRNA's making more than surgeons? Please show me a comparison with numbers that proves that a CRNA is making more than the surgeon in the exat same geographical area that are equally busy.

It would be a safe bet to say that if a CRNA is working similar amts as a surgeon in the same area than the surgeon is making a good amount more.
Now if the CRNA is working at 3 different places putting in 80hrs a week and the sureon is doing 1-2 cases a week than just maybe it is possible but overall in the real world away from the realm of paranoid schitzo anesthesia residents the CRNA is not gonna make even close to the surgeon.
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Firstly, the guy named Nitecap is a STUDENT CRNA. There are documented cases of surgeons who went off on a limb and used their own license to cover the CRNA WITHOUT an anesthesiologist. So out of curiosity do you all think that is safe? I think most rational individuals like yourselves woudl agree tht having unsupervised nurses doing cases is literally "hanging on the edge of danger". I suspect you all would rather use your licenses to perform surgery and not be concerned abut what goes on on the other side of the 'sheet'.

oh by the way, this was Nitecap (student CRNA's) response to a case we presented which concerned a surgeon. His words to what he would have said to the surgeon:
"....I would have told him to eat a dick.."

Hey if that's how you all like STUDENT nurses talking to ya'll, well I suppose the real CRNAs then have kinder words to tell ya.

Seirously though. Look at the impact anesthesiologists have done to the administration of Anesthesia. Close to 1/2 of the surgeries had a very hihg mortality. it wasnt until physicians took over the field of anesthesia, that it became a science. Back in the day when it was just passing some ether, fires and death were a common occurence.

I think doctors, on both sides of the curtain are who will bring quality healthcare to OUR patients.
 
I find the cavalier attitude of the surgeons on this board amusing. They think they are immune from midlevels pushing for expansion into surgery.

Its coming your way too, surgeons, and when it happens your tune will change VERY QUICKLY.

Some day, maybe 10 or 15 years from now, some state nursing board, in say New Mexico or Washington is going to change their regulations by defining surgery as "advanced practice nursing" and set up a new program for RNFA (Registered Nurse First Assistants) to take extra training and be able to do simple gen surg procedures like lap chole solo. And when that happens, there's not a DAMN THING the surgeons can do about it because state medical boards have ZERO OVERSIGHT over nursing scope of practice.

The day after that happens, surgeons are going to be ranting and raving on this board about how they are so much better than nurses and that nurses cant possibly do even the most simple surgical cases.

So remember this thread surgeons. Remember that all the other medical specialties thought they, too, were immune to midlevels and need not concern themselves with nurses.
 
MacGyver said:
I find the cavalier attitude of the surgeons on this board amusing. They think they are immune from midlevels pushing for expansion into surgery.

Its coming your way too, surgeons, and when it happens your tune will change VERY QUICKLY.

Some day, maybe 10 or 15 years from now, some state nursing board, in say New Mexico or Washington is going to change their regulations by defining surgery as "advanced practice nursing" and set up a new program for RNFA (Registered Nurse First Assistants) to take extra training and be able to do simple gen surg procedures like lap chole solo. And when that happens, there's not a DAMN THING the surgeons can do about it because state medical boards have ZERO OVERSIGHT over nursing scope of practice.

The day after that happens, surgeons are going to be ranting and raving on this board about how they are so much better than nurses and that nurses cant possibly do even the most simple surgical cases.

So remember this thread surgeons. Remember that all the other medical specialties thought they, too, were immune to midlevels and need not concern themselves with nurses.
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That is insane and will never happen. CRNA's didnt just crawl out of some Anesthesiologist's A$$ a few decades ago. We have been around for 100yrs and are strongly established with documented safe and quality practice. We provide the majority of the anesthetics to all military branches including on the combat field. It was actually Surgeons that increased the number of Nurses delivering anesthetics in the very early 1900's. Dr. Mayo had his own personal Nurse Anesthetist that did 10's of thousands of his cases. Thanks surgery your forefathers that have given me a great career.
 
The US is a free market economy, were markets providing "similar" comodities are supoposed to compete with each other, fairly, for consumers.

The ULTIMATE consumer in the "surgery market" is the patient....NOT the surgeon. So if the Anesthesiologists REALY want to block the CRNAs, THEY SHOULD TARGET THE PATIENTS DIRECLY, instead of convincing surgeons to use their services. They should do that the old-fashon way....educational TV/radio/highway flyer Ads payed for by the American Society of Anesthesiologists.

You see, if a patient demands that his anesthesia be administered by an Anesthesiologist, then the surgeon cannot do anything but comply...the patient always has the Ultimate say.

The thing is that you do not see the ASA puting on TV "info-mercials", nor are they actively competing with the CRNAs....WHY?

Well, from my humble experience with anesthesia, I noticed that the "anesthesia big dogs" actually desire and hire CRNAs!!!! Why? More Money for them!

As I stated before, the CHAIRMAN of the Anesthesiology depatement at my school (who is the CEO of the anesthesiology group that is contracted by the University hospital to provide anesthesia services there) said that "some CRNAs are better than some Anesthesiologists". He hires a butt load of CRNAs in his group.

So it seems that the "anesthesiology elders" really do not care about the threat from CRNAs. It is only the med. students and residents who are more concerned with the CRNA issue......maybe because they do not see the Millions that are going into the CEO-Anesthesiologists as a result of the capital saved from hiring CRNAs,..YET!
 
nitecap said:
That is insane and will never happen.
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Same thing was said years ago before NPs got script rights

Same thing was said years ago before NPs got independent practice

Now we are supposed to believe that all of a sudden, NPs will just stop pushing for increased scope in surgery? That NPs are going to invade EVERY SINGLE OTHER MEDICAL SPECIALTY, yet when it comes to surgery they are just going to say "we dont want that?"

Yeah right. We know your agenda.
 
Would you go to a hospital and let an NP do your surgery? When the surgeon says, oh, I won't be doing your gallbladder, Nurse Mary will be doing it, you can bet your ass the patient will have something to say about that. No one in their right mind would let an NP/RNFA/PA/CST/CSA/XYZ do their surgery when they can have a surgeon do it.

NPs doing cases solo will never happen. Patients won't let it happen.
 
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mysophobe said:
Would you go to a hospital and let an NP do your surgery? When the surgeon says, oh, I won't be doing your gallbladder, Nurse Mary will be doing it, you can bet your ass the patient will have something to say about that. No one in their right mind would let an NP/RNFA/PA/CST/CSA/XYZ do their surgery when they can have a surgeon do it.

NPs doing cases solo will never happen. Patients won't let it happen.
Click to expand...
Dude, I get your point with the NP doing surgery (which I've seen is a threat for you guys). See, teh point is this. As in the anesthesia world, the CRNA will come into the room and be like "hi, i'm the anesthesist , and I wil be providing the anesthesia this morning,etc". Do you really think the PATIENT knows the difference b/w an anesthesist or an anesthesiologists? in fact some of the nurses wont even say theyre an anesthesist, they'll just say "hi i'll be providing the anesthesia for you during the surgery".

what's my point? Well the NP can walk in and be like, "Hi Mr. Smith, I hope you are doing well. I'll be removing your gallbladder today...." When that nurse walks in with her LONG white coat (which most NPs are akin to already) and her stethoscope in her jacket, do you really think the PATIENT will know the difference? Nope.

So guys, the bottom line is you can just ignore the issue now. OR realize that we are ALL prone to midlevel penetration. Working together we can preven this sort of infiltration to OUR professions. Do you know why managed care was soo successful in the 80-90s? They preyed on the fact that DOCTORS never banned together and used that leverage to negotiate better reimbursements. if you surgeons think that your reimbursements are bad right now (which I agree with), just think what it will be AFTER midlevel infiltration.....
 
ThinkFast007 said:
Do you know why managed care was soo successful in the 80-90s? They preyed on the fact that DOCTORS never banned together and used that leverage to negotiate better reimbursements.
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Actually, doctors are prohibited from doing so by law.
 
KentW said:
Actually, doctors are prohibited from doing so by law.
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i realize there is something called the anti-trust law. however, this has nothing to do with it. so what about managed care companies banning together to set capitation standards and PMPMs ?? That's kosher right? I'm not advocating breaking the law. but I am advocating using the correct means to get fairer compensation for all PHYSICIANS.
 
ThinkFast007 said:
i realize there is something called the anti-trust law. however, this has nothing to do with it.
Click to expand...

It's related. There is a variety of legislation in place which makes it virtually impossible for doctors to negotiate as a group. Read this for more info.
 
KentW said:
It's related. There is a variety of legislation in place which makes it virtually impossible for doctors to negotiate as a group. Read this for more info.
Click to expand...
no one said anything about Physician Unions. LARGE multi-specialty groups are perfectly legit. large multi-specialty groups can negotiate better reimbursements.

KentW- Bottom line, either you're with us or not. If not, that's cool. Good lawyers can figure out ways to get around things if it had to come to that. But like i said earlier, multispecialty groups...and I MEAN LARGE ones are totally OK.

also:
1) labor unions can be formed if you are a HOSPITAL employee. Which is what Anesthesiologists, pathologists, radiologists are...not sure of surgeons.

2) I've actually been told this by a contract specialist, and it's also written about in your article:
What about bargaining with payers, managed care plans, or HMOs? There is a range of answers. On the safe end, non-employee union members or other physician groups can use the so-called "messenger model", in which one person or entity negotiates on behalf of the group on an individual by individual basis. The use of the messenger prevents any "competitor" from comparing or fixing prices with any other competitor.

KentW, I realize you employ NPs/PAs who are helping you produce some good revenue. THat's why you arent concerned. By using them, you are able to see more patients and mk more money for yourself. Sadly, it appears you have no concern for what the reimbursement rates will be for the young physicians that are coming up. This is very unforunate.
 
ThinkFast007 said:
no one said anything about Physician Unions.
Click to expand...

Read past the headline. The article provides a nice, cursory overview of relevant legal barriers to collective bargaining, although it's a little dated (it was the best I could find with a quick Google search).

large multi-specialty groups can negotiate better reimbursements.
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Yes, but unless you're an employee of that group, it won't help you. I'm in a large, multispecialty group, so I'm not unfamiliar with this subject.

ThinkFast007 said:
KentW, I realize you employ NPs/PAs
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Actually, no, I don't. I have no interest in defending statements that I haven't made. Have a nice day. 🙄
 
ThinkFast007 said:
As in the anesthesia world, the CRNA will come into the room and be like "hi, i'm the anesthesist , and I wil be providing the anesthesia this morning,etc". Do you really think the PATIENT knows the difference b/w an anesthesist or an anesthesiologists? in fact some of the nurses wont even say theyre an anesthesist, they'll just say "hi i'll be providing the anesthesia for you during the surgery".

what's my point? Well the NP can walk in and be like, "Hi Mr. Smith, I hope you are doing well. I'll be removing your gallbladder today...."
Click to expand...

True. I'd hope that healthcare providers would introduce themselves by name, though, when meeting a patient for the first time. I certainly do. "Good morning, Mr./Mrs. Smith, I'm Dr. X, from General Surgery." Not just "Hi, I'm from General Surgery." As a patient, wouldn't you at least like to know that person's name?

Then you'd have to include title, or position, no? Unless you do what some people do, and just introduce yourself with your full name: "Hello, I'm Jane Doe from anesthesiology/surgery."
 
Blade28 said:
True. I'd hope that healthcare providers would introduce themselves by name, though, when meeting a patient for the first time. I certainly do. "Good morning, Mr./Mrs. Smith, I'm Dr. X, from General Surgery." Not just "Hi, I'm from General Surgery." As a patient, wouldn't you at least like to know that person's name?

Then you'd have to include title, or position, no? Unless you do what some people do, and just introduce yourself with your full name: "Hello, I'm Jane Doe from anesthesiology/surgery."
Click to expand...
Hey i'm with you.

But let's be honest with ourselves. When I was on my third/fourth year surg/anes electives i've seen plenty of docs just go in there, "Hi i'm jack smith from surgery, we're gonna be taking care of that knee today". The thing is the patients know NO better. They have no clue. you and I already konw how nervous they are before surgery. I really do not think that a patient would question the credentials of someone that goes to be doing surgery/anesthesia for them, cuz they're scared to begin with. It's a sad truth.

We as future physican providers, etc must congregate and increase public awareness of this. As i stated on the Anesthesiology forum, there are plenty of ads that the orthopedists run in airports etc. We should run them too. Ads that inform the patient. Show the general public that there are midlevels out there and that it would best suite them to request BOARD CERTIFIED SURGEONS/ANESTHESIOLOGISTS. in fact I know 2 groups of surgeons, who when contract out anesthesiologists, require that the anesthesia group is comprised of ONLY anesthesiologists. i think it sets up a better workign environment for all of us 👍

Seriously guys, Surgery and Anesthesiology United is the only way I see the future secure for BOTH of our specialties. I think the concerns of midlevel infiltration can be addressed ONLy if we both work together.
 
ThinkFast007 said:
We as future physican providers, etc must congregate and increase public awareness of this. As i stated on the Anesthesiology forum, there are plenty of ads that the orthopedists run in airports etc. We should run them too. Ads that inform the patient. Show the general public that there are midlevels out there and that it would best suite them to request BOARD CERTIFIED SURGEONS/ANESTHESIOLOGISTS. in fact I know 2 groups of surgeons, who when contract out anesthesiologists, require that the anesthesia group is comprised of ONLY anesthesiologists. i think it sets up a better workign environment for all of us 👍

Seriously guys, Surgery and Anesthesiology United is the only way I see the future secure for BOTH of our specialties. I think the concerns of midlevel infiltration can be addressed ONLy if we both work together.
Click to expand...

Dude..you are beating around the bush, and not going to the source of your problem:

-Anesthesiologists who are hiring CRNA's in their anesthesia groups (to increase their bottom line).

-The misinformed patient population.

Targeting surgeons will do you nothing. They have their own "crap" to worry about.

The core of your problem is that established Anesthesiologists want CRNA's.

You sould do what pharmaceutical companies do-

-Target the patient population with eduational ads (so that they request a MDA at the time when they schedule their surgery..days before their surgery)

-Be vocal/active in the ASA (and convince "your elders" to stop/limit the hiring of CRNAs.

You should be trageting the RICH Anesthesiologits who are hiring the CRNAs in their groups...NOT the overworked/poor surgeons!!!

You should go to the source of the problem, which is in your own backyard.
 
mysophobe said:
Would you go to a hospital and let an NP do your surgery? When the surgeon says, oh, I won't be doing your gallbladder, Nurse Mary will be doing it, you can bet your ass the patient will have something to say about that. No one in their right mind would let an NP/RNFA/PA/CST/CSA/XYZ do their surgery when they can have a surgeon do it.

NPs doing cases solo will never happen. Patients won't let it happen.
Click to expand...

Same arguments were used before NPs got script rights and independent practice

"Nobody would EVER go to a nurse to manage their diabetes!"

"Nobody would EVER go to an independent NP clinic to get diagnosed!"

"Nobody would EVER let an NP write scripts without MD cosignature!"

"No patient would EVER rely on an NP as their PCP!"

You are in for a rude wake up call if you think NPs will never penetrate surgery because "patients wont allow it."
 
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