Are You Ready For Private Practice?

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jetproppilot

jetproppilot

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(ADDENDUM: I wrote this a cuppla years ago. Its got alotta useful information in it for you. I'm bumping it for the benefit of my CA-3 colleagues who may have missed it and are gonna be on their own in a few months.)


I'm starting a thread that I hope will be useful for the current and future CA-3s out there. At the end of this year, CA-3s, your life will take a dramatic change. You will have clinical responsibilities where your decision is the final decision. You will be faced with the new dillemas of becoming a team player in a group practice, where every decision/opinion/action you take will be scrutinized, with the end result being whether you become a partner or not. And you and I know your goal is to become a partner.......job security being the primary objective; major c-notes being the secondary objective.

Problem is, in academia where most of you currently reside, there is no guidance for emerging practitioners....academia will guide you up to and including your last case as a resident. Thats it. After that last anesthetizing case you perform, AMFYOYO. See ya. Youre on your own. Buh-bye.

My last case at Tulane (circa June 30th, 1996) was a 3 hour hysterectomy. After I was done, I went to my locker and cleaned out my stuff.. That was it. No........"So Bill, whats the practice that you're going to like? Group? Hmmmm....we've got a few former private practice dudes around here....why don't we have you talk with them to give you a little perspective of private practice life, OK?"......

.....nothing to that effect happened. And I venture to say most residencies out there are similar in that minimal advice is given to finishing-senior-residents.

This is a problem with academia, Dudes.

Things need to change in academia....most graduating residents matriculate into a private practice model and yet this IMPORTANT fact is ignored in your training. You are not prepared clinically, emotionally, and business-wise for such a career jump....a jump that we all make. Hopefully some academic-deities will read this and realize the existent black hole in their residency program.

My goal is to recruit my fellow private practice dudes (Mil, Noy, UT) to post here in an effort to guide you through the right way to matriculate into a private group from residency, with the ultimate goal being you hit partnership (read: 6th round NFL draft pick salary).

And here, I'll take a bit of a tangent for med students/interns.

This kinda info may not be for you.

Maybe you're an individualist destined to secure power in your practice of medicine.

I respect that.

I'll also tell you that if you've selected anesthesia as a specialty you're probably not destined for stardom. Yeah, if you really want it you can become a John Tinker/Alan Kaye/Michael Roizen. But most of us out here making our living at this profession are flying under the radar. By definition we are the offensive line of medicine. We are the players that nobody really cares about.

You're either comfortable with that or you're not.

And if you are not, you probably need to select another specialty. Deep-six your anesthesia selection and go for heart surgery. Transplant. Family Practice/Pediatrics/Internal Medicine in a rural area where youre da man. Something that you can potentially have your name in the paper for.

And because of the (egocentric) personalities I've seen here on SDN and because of my periodic exposures to unhappy anesthesiologists, I'm gonna string this out a bit..... and I want you to think about this long and hard.....if you select anesthesia to pay your bills you will never be more than a supporting actor. The Brad-Pitt-of-surgeons will always steal the thunder. They are the glory boys. You are the (metaphorically) short, bald dude on Seinfeld.

A crucial aspect of the perioperative environment?

Absolutely.

The lead role?

Absolutely not. You are the offensive lineman. The punter that comes on in a crutch and kicks a fifty-six-yard punt. Or a field-goal kicker. You are Morten Anderson. Mr. Carney of the New Orleans Saints. Grammatica.

Again, get comfortable with this. And if this makes you uncomfortable take another route that'll satisfy your needs.

Are you comfortable being a sixth-round offensive lineman for the Tampa Bay Buccaneers?

Yes?

Great.

Then hear me out cuz you can personally benefit greatly. You can be in the top tier of reimbursement in the physician milleau.

TOTALLY different ballgame out here compared to the academic environment you are used to, folks.

Out here its about accomodating surgeons (without giving a "kiss-ass" impression), providing superior patient care, and getting the cases done as fast and efficient as possible.

Thats it.

Pretty simple s h it, huh?

Kinda like poker in that it takes a few minutes to learn but a lifetime to master.

So I'll start with a few suggestions and I'm sure my colleagues will chime in with ARE YOU READY FOR PRIVATE PRACTICE suggestions.

1) Now that you're employed by C-NOTE ANESTHESIA, LLC, its important, at least initiallly, to lose your individuality. Don't take that the wrong way. No, the group doesnt want a robot. They picked you, so thats a good thing. What a group doesnt want out of a new-hire is a dude/dudette who is inflexible, who insists on doing a certain situation a certain way..

...but heres a very important kicker....they arent gonna point this out to you. You either figure this out on your own and get accepted, or....uhhhhhh....you fall into the unliked, inflexible category.

Clandestine profiling going on???....Absolutely.

You may never hear a negative comment until your pink slip is presented. You either make the grade or you don't. On your own.

Most successful private groups are successful for a cuppla reasons: they are deft at anesthesia, and they know how to keep people happy. Successful anesthesia groups are able, amicable, and available.

You're used to putting the IJ in a CABG before induction but your new group typically does it after? Time for you to adapt to the group way.....you like a tube for knee scopes but the group exclusively uses LMAs? Youre used to regional for fem-pops but your new group does all GA??....same message....unless patient outcome is affected, fall into line....


Your new group will expect you to fall into line, not make waves, all the while with a smile on your face. Make conversation with the ortho dude during the 11pm hip ORIF. Make the impression that no matter what the request, you're happy to do it. Being a new-hire is not the time to take a stand about an issue. If presented with something weird, like a 2am BTL, do it. Then the next morning, call one of the senior partners and ask them if what occurred is normal. If it is not, the senior partner will address it. Not your turf right now. Later when you are a partner, yes. Now, no.

2)Make yourself irreplaceable. Private practice is all about speed, efficiency, and proficiency. Don't waste time. Don't do twenty minute pre-ops. Don't take twenty minutes to do anything. If you are taking twenty minutes right now to do an A-line/central line/epidural/etc, work on it NOW. Make yourself da masta. Problems? Seek out a deft attending and watch how he does it. Emulate him.

You are a CA-3 now. You need to concentrate on making yourself better, right now. Pick up the pace on your labor epidurals. Yeah, nobody gives a s h it how long you take right now....but come July on your first month with C-Note Anesthesia LLC, if you leave the main OR to go put in an eoidural and you return 45 minutes later, thats a problem.
More optimistically, if you leave the main OR for a labor epidural and you are back on the floor 15 minutes later, the senior partners will notice that.

3) There are a handful of procedures that we private practice dudes do every day. And the more deft you are at those procedures as a new hire, the better you're gonna look. Central lines, A lines, epidurals, spinals, interscalene blocs, axillary blocks, and of course intubations, are the crux of our procedural world. The better you are at those procedures, the better you're gonna look. Make an effort right now, as a resident, to optimize your skills. Think about speed, something your academic-attendings won't emphasize........believe me, they should be emphasizing speed...but thats another thread altogether.......

....are you at a residency where thats impossible? Where you do three interscalenes annually and yet the group you joined does three interscalenes daily?....its all good.......just be prepared to humbly learn from your senior partners. Watch them. Learn from them. Emulate them. All the while thinking about the Holy Grail....

4) Accept the fact that for at least the first year of private practice, you need to just go-with-the-flow. Don't make waves. Don't cancel cases unless you are absolutely sure its gonna affect patient outcome. Don't complain about your schedule. Don't make enemies with surgeons/CRNAs/circulators/administrators.

Gotta orthopedist wanting to do a hip ORIF on an ICU patient in florid pulmonary edema (yep, a situation I remember)? Well you gotta step up to the plate and say absolutely not.

Conversely, gotta true urgent-yet-not-emergent case being postponed 2 more hours because of NPO issues, with the surgeon sitting in the doctors lounge? Step up to the mike. Call for the patient.

5) So You're on call today. You are running the board.

Anticipate. Think ahead. Dr Smith the orthopedist just started a knee scope. How long does he take? 30 minutes? If he's got a case to follow, have you sent for the next patient? If the next case requires intervention by you (i.e. epidural for TKA), make sure everything is finished before Dr. Smith is done with his knee scope. Have the to-follow knee replacement in the holding area, epidural in and dosed before he is finished.

Go to the front desk frequently. Ask "has anybody pre-opped?" That one question will keep you informed if you've been busy doing something else......HAS ANYBODY PREOPPED???....if the answer is yes then you may be behind the eight-ball already. It is difficult, but doable, to stay ahead of an OR schedule. But thats your job. Thats how you can make yourself invaluable. Staying ahead of the OR schedule.

6) Be flexible. Hmmmmm....senior partner going to Las Vegas in November and needs you to switch a cuppla calls? "No problem, dude" is the right answer. I'm not implying that you incur abusive behavior, but hey, this is real life....and people periodically need to switch schedules. Make it a point during your partnership-trek to be flexible. Cuz this is the kinda s h it thats remembered come your partner-anniversary day

So thats a good start, albeit introductory. Theres a million things we need to cover on this subject, and I want my resident colleagues out there to hear the salient ones concerning successful private practice matriculation.

REAL WORLD info. Period. No holds barred. Love it or leave it. Thats how it goes down out here.



MIL, NOY, UT et al,

chime in with your wisdom.
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Last edited:
You may never hear a negative comment until your pink slip is presented. You either make the grade or you don't. On your own.
Click to expand...


that's my M.O.
 
Members don't see this ad :)
JPP,
Thanks for stepping up to the plate (again). That'll be me in 9 months. I'll keep practicing the speed thing, although I'm def at an institution that ISN'T about speed.

Cheers,
PMMD

jetproppilot said:
I'm starting a thread that I hope will be useful for the current and future CA-3s out there. At the end of this year, CA-3s, your life will take a dramatic change. You will have clinical responsibilities where your decision is the final decision. You will be faced with the new dillemas of becoming a team player in a group practice, where every decision/opinion/action you take will be scrutinized, with the end result being whether you become a partner or not. And you and I know your goal is to become a partner.......job security being the primary objective; major c-notes being the secondary objective.

Problem is, in academia where most of you currently reside, there is no guidance for emerging practitioners....academia will guide you up to and including your last case as a resident. Thats it. After that last anesthetizing case you perform, AMFYOYO. See ya. Youre on your own. Buh-bye.

My last case at Tulane (circa June 30th, 1996) was a 3 hour hysterectomy (HAHAHAHAHHAHAHA.....3 hour hysterectomy....gimme a f u kking break.....only in academia.....). After I was done, I went to my locker and cleaned out my s h it. That was it. No........"So Bill, whats the practice that you're going to like? Group? Hmmmm....we've got a few former private practice dudes around here....why don't we have you talk with them to give you a little perspective of private practice life, OK?"......

.....nothing to that effect happened. And I venture to say most residencies out there are similar in that minimal advice is given to finishing-senior-residents.

This is a problem with academia, Dudes.

Things need to change in academia....most graduating residents matriculate into a private practice model and yet this IMPORTANT fact is ignored in your training. You are not prepared clinically, emotionally, and business-wise for such a career jump....a jump that we all make. Hopefully some academic-deities will read this and realize the existent black hole in their residency program.

My goal is to recruit my fellow private practice dudes (Mil, Noy, UT) to post here in an effort to guide you through the right way to matriculate into a private group from residency, with the ultimate goal being you hit partnership (read: 6th round NFL draft pick salary).

And here, I'll take a bit of a tangent for med students/interns.

This kinda info may not be for you.

Maybe you're an individualist destined to secure power in your practice of medicine.

I respect that.

I'll also tell you that if you've selected anesthesia as a specialty you're probably not destined for stardom. Yeah, if you really want it you can become a John Tinker/Alan Kaye/Michael Roizen. But most of us out here making our living at this profession are flying under the radar. By definition we are the offensive line of medicine. We are the players that nobody really cares about.

You're either comfortable with that or you're not.

And if you are not, you probably need to select another specialty. Deep-six your anesthesia selection and go for heart surgery. Transplant. Family Practice/Pediatrics/Internal Medicine in a rural area where youre da man. Something that you can potentially have your name in the paper for.

And because of the (egocentric) personalities I've seen here on SDN and because of my periodic exposures to unhappy anesthesiologists, I'm gonna string this out a bit..... and I want you to think about this long and hard.....if you select anesthesia to pay your bills you will never be more than a supporting actor. The Brad-Pitt-of-surgeons will always steal the thunder. They are the glory boys. You are the (metaphorically) short, bald dude on Seinfeld.

A crucial aspect of the perioperative environment?

Absolutely.

The lead role?

Absolutely not. You are the offensive lineman. The punter that comes on in a crutch and kicks a fifty-six-yard punt. Or a field-goal kicker. You are Morten Anderson. Mr. Carney of the New Orleans Saints. Grammatica.

Again, get comfortable with this. And if this makes you uncomfortable take another route that'll satisfy your needs.

Are you comfortable being a sixth-round offensive lineman for the Tampa Bay Buccaneers?

Yes?

Great.

Then hear me out cuz you can personally benefit greatly. You can be in the top tier of reimbursement in the physician milleau.

TOTALLY different ballgame out here compared to the academic environment you are used to, folks.

Out here its about accomodating surgeons (without giving a "kiss-ass" impression), providing superior patient care, and getting the cases done as fast and efficient as possible.

Thats it.

Pretty simple s h it, huh?

Kinda like poker in that it takes a few minutes to learn but a lifetime to master.

So I'll start with a few suggestions and I'm sure my colleagues will chime in with ARE YOU READY FOR PRIVATE PRACTICE suggestions.

1) Now that you're employed by C-NOTE ANESTHESIA, LLC, its important, at least initiallly, to lose your individuality. Don't take that the wrong way. No, the group doesnt want a robot. They picked you, so thats a good thing. What a group doesnt want out of a new-hire is a dude/dudette who is inflexible, who insists on doing a certain situation a certain way..

...but heres a very important kicker....they arent gonna point this out to you. You either figure this out on your own and get accepted, or....uhhhhhh....you fall into the unliked, inflexible category.

Clandestine profiling going on???....Absolutely.

You may never hear a negative comment until your pink slip is presented. You either make the grade or you don't. On your own.

Most successful private groups are successful for a cuppla reasons: they are deft at anesthesia, and they know how to keep people happy. Successful anesthesia groups are able, amicable, and available.

You're used to putting the IJ in a CABG before induction but your new group typically does it after? Time for you to adapt to the group way.....you like a tube for knee scopes but the group exclusively uses LMAs? Youre used to regional for fem-pops but your new group does all GA??....same message....unless patient outcome is affected, fall into line....


Your new group will expect you to fall into line, not make waves, all the while with a smile on your face. Make conversation with the ortho dude during the 11pm hip ORIF. Make the impression that no matter what the request, you're happy to do it. Being a new-hire is not the time to take a stand about an issue. If presented with something weird, like a 2am BTL, do it. Then the next morning, call one of the senior partners and ask them if what occurred is normal. If it is not, the senior partner will address it. Not your turf right now. Later when you are a partner, yes. Now, no.

2)Make yourself irreplaceable. Private practice is all about speed, efficiency, and proficiency. Don't waste time. Don't do twenty minute pre-ops. Don't take twenty minutes to do anything. If you are taking twenty minutes right now to do an A-line/central line/epidural/etc, work on it NOW. Make yourself da masta. Problems? Seek out a deft attending and watch how he does it. Emulate him.

You are a CA-3 now. You need to concentrate on making yourself better, right now. Pick up the pace on your labor epidurals. Yeah, nobody gives a s h it how long you take right now....but come July on your first month with C-Note Anesthesia LLC, if you leave the main OR to go put in an eoidural and you return 45 minutes later, thats a problem.
More optimistically, if you leave the main OR for a labor epidural and you are back on the floor 15 minutes later, the senior partners will notice that.

3) There are a handful of procedures that we private practice dudes do every day. And the more deft you are at those procedures as a new hire, the better you're gonna look. Central lines, A lines, epidurals, spinals, interscalene blocs, axillary blocks, and of course intubations, are the crux of our procedural world. The better you are at those procedures, the better you're gonna look. Make an effort right now, as a resident, to optimize your skills. Think about speed, something your academic-attendings won't emphasize........believe me, they should be emphasizing speed...but thats another thread altogether.......

....are you at a residency where thats impossible? Where you do three interscalenes annually and yet the group you joined does three interscalenes daily?....its all good.......just be prepared to humbly learn from your senior partners. Watch them. Learn from them. Emulate them. All the while thinking about the Holy Grail....

4) Accept the fact that for at least the first year of private practice, you need to just go-with-the-flow. Don't make waves. Don't cancel cases unless you are absolutely sure its gonna affect patient outcome. Don't complain about your schedule. Don't make enemies with surgeons/CRNAs/circulators/administrators.

Gotta orthopedist wanting to do a hip ORIF on an ICU patient in florid pulmonary edema (yep, a situation I remember)? Well you gotta step up to the plate and say absolutely not.

Conversely, gotta true urgent-yet-not-emergent case being postponed 2 more hours because of NPO issues, with the surgeon sitting in the doctors lounge? Step up to the mike. Call for the patient.

5) So You're on call today. You are running the board.

Anticipate. Think ahead. Dr Smith the orthopedist just started a knee scope. How long does he take? 30 minutes? If he's got a case to follow, have you sent for the next patient? If the next case requires intervention by you (i.e. epidural for TKA), make sure everything is finished before Dr. Smith is done with his knee scope. Have the to-follow knee replacement in the holding area, epidural in and dosed before he is finished.

Go to the front desk frequently. Ask "has anybody pre-opped?" That one question will keep you informed if you've been busy doing something else......HAS ANYBODY PREOPPED???....if the answer is yes then you may be behind the eight-ball already. It is difficult, but doable, to stay ahead of an OR schedule. But thats your job. Thats how you can make yourself invaluable. Staying ahead of the OR schedule.

6) Be flexible. Hmmmmm....senior partner going to Las Vegas in November and needs you to switch a cuppla calls? "No problem, dude" is the right answer. I'm not implying that you incur abusive behavior, but hey, this is real life....and people periodically need to switch schedules. Make it a point during your partnership-trek to be flexible. Cuz this is the kinda s h it thats remembered come your partner-anniversary day

So thats a good start, albeit introductory. Theres a million things we need to cover on this subject, and I want my resident colleagues out there to hear the salient ones concerning successful private practice matriculation.

REAL WORLD info. Period. No holds barred. Love it or leave it. Thats how it goes down out here.



MIL, NOY, UT et al,

chime in with your wisdom.
Click to expand...
 
kick ass post...still a newly inbreeded CA1 here but great to keep these points in my mind as these next few yrs go by (hopefully fly by)

J👍
 
Jet seems like someone the Academic community would benefit from moreso than the Private Community 😀
 
Yes speed is everything.

Some other points to remember. Don't talk on your cell phone during the case unless necessary. Don't read in the OR until you know it is safe and not bothersome to others (surgeons and nurses). Once you have established a raport and instilled some confidence of others in your skills, then reading may be tolerated. Do stand and pay attention to the case as it goes on. Do make conversation with the OR crew and surgeon. Be social.
 
jetproppilot said:
if you select anesthesia to pay your bills you will never be more than a supporting actor. The Brad-Pitt-of-surgeons will always steal the thunder. They are the glory boys. You are the (metaphorically) short, bald dude on Seinfeld.

A crucial aspect of the perioperative environment?

Absolutely.

The lead role?

Absolutely not. You are the offensive lineman. The punter that comes on in a crutch and kicks a fifty-six-yard punt. Or a field-goal kicker. You are Morten Anderson. Mr. Carney of the New Orleans Saints. Grammatica.

[/B]
Click to expand...
Munoz1.jpg

I have no problem being this guy, show up everyday, bust my ass, grind it out like Mike McD, get maybe a few pats on the back, walk away with a ring or two.
 
jetproppilot said:
Out here its about accomodating surgeons (without giving a "kiss-ass" impression), providing superior patient care, and getting the cases done as fast and efficient as possible.
Click to expand...

so, let me more succinctly summarize: no one likes a slow, lazy, inept complainer. that's pretty much all you needed to say.

as one of those likely "egocentric" (i think you probably meant egotistical) residents you were referring to, i can also tell you this: don't be a doormat. all physicians - hell, all people - are ultimately egocentric, especially when it comes to their careers and family. you don't have to subrogate your rights to be the same way just because you are new employee (yes, you are just a worker bee when you start ANY job somewhere as "new blood" - heed jet's advice in that regard.)

this is the most important thing you said in your post:

jetproppilot said:
Being a new-hire is not the time to take a stand about an issue. If presented with something weird, like a 2am BTL, do it. Then the next morning, call one of the senior partners and ask them if what occurred is normal. If it is not, the senior partner will address it. Not your turf right now.
Click to expand...

it's your right - your responsibility - to say something. the problem arises is that some people are just simply clueless as to the appropriate way to seek redress for complaints. you have to do this cleverly and politically. if you can't, then keep your mouth shut and start looking for another job somewhere else. because, if you take that crap quietly, who do you think they are going to call next time? think about that...

so, i want to make this completely clear as well. if you ask by your actions to be **** upon by anyone in a practice, you will. the true "problem employee" is a rare thing despite what others may want to make you believe. if you show up and do what you're supposed to do when you're supposed to do it, you'll do fine. the job market right now dictates that. and, when the time is right, stand up for yourself and asked to be compensated appropriately. if it's becomes clear that you're not going to make partner, then it was already time to start looking somewhere else six months prior to that point.

so, be professional, be courteous, and be competent. you don't have to kiss anyone's ass to accomplish that, and you shouldn't. if you act like a doormat, you will get walked on.

trust me, i've got YEARS of real world experience behind me prior to going down this path. and, as someone who's about to graduate from my program, i'm having no problems finding a multitude of folks who are more than willing to pay for my services. play the game and play it well and you will thrive.

jetproppilot said:
Make yourself irreplaceable.
Click to expand...

yes, true. but, easier said in an internet forum than done. but, never let someone else exploit your skills and talents.

so, in summary, yes, you might have to bite the bullet for a year or two to be in the practice and location you want to be, but if they start asking you to do bizarre things, treating you like ****, or taking advantage of you in any way, don't wait for that unexpected pink slip. hand them your resignation. there are plenty of other jobs out there right now.
 
VolatileAgent said:
so, let me more succinctly summarize: no one likes a slow, lazy, inept complainer. that's pretty much all you needed to say.

as one of those likely "egocentric" (i think you probably meant egotistical) residents you were referring to, i can also tell you this: don't be a doormat. all physicians - hell, all people - are ultimately egocentric, especially when it comes to their careers and family. you don't have to subrogate your rights to be the same way just because you are new employee (yes, you are just a worker bee when you start ANY job somewhere as "new blood" - heed jet's advice in that regard.)

this is the most important thing you said in your post:



it's your right - your responsibility - to say something. the problem arises is that some people are just simply clueless as to the appropriate way to seek redress for complaints. you have to do this cleverly and politically. if you can't, then keep your mouth shut and start looking for another job somewhere else. because, if you take that crap quietly, who do you think they are going to call next time? think about that...

so, i want to make this completely clear as well. if you ask by your actions to be **** upon by anyone in a practice, you will. the true "problem employee" is a rare thing despite what others may want to make you believe. if you show up and do what you're supposed to do when you're supposed to do it, you'll do fine. the job market right now dictates that. and, when the time is right, stand up for yourself and asked to be compensated appropriately. if it's becomes clear that you're not going to make partner, then it was already time to start looking somewhere else six months prior to that point.

so, be professional, be courteous, and be competent. you don't have to kiss anyone's ass to accomplish that, and you shouldn't. if you act like a doormat, you will get walked on.

trust me, i've got YEARS of real world experience behind me prior to going down this path. and, as someone who's about to graduate from my program, i'm having no problems finding a multitude of folks who are more than willing to pay for my services. play the game and play it well and you will thrive.



yes, true. but, easier said in an internet forum than done. but, never let someone else exploit your skills and talents.

so, in summary, yes, you might have to bite the bullet for a year or two to be in the practice and location you want to be, but if they start asking you to do bizarre things, treating you like ****, or taking advantage of you in any way, don't wait for that unexpected pink slip. hand them your resignation. there are plenty of other jobs out there right now.
Click to expand...

It is very hard to tell the tone of someone's posts on the internet.....or what your personality is like...or whatever....

Having said that....you sound like you're going to have problems....seems like you have a chip on your shoulder already....and you haven't even finished residency yet.

Just my 2 cents....job markets aren't what they seem.....especially as viewed from the eyes of a new grad with no years of practice experience....

But this is just an internet forum....can't really tell what you're like....but, like I said....the way you string those keystrokes together....gives me the impression of someone who will become the bitter, I'm getting screwed by everyone....kind of anesthesiologist.
 
militarymd said:
gives me the impression of someone who will become the bitter, I'm getting screwed by everyone....kind of anesthesiologist.
Click to expand...

eh... perhaps... then, again... maybe it simply takes one to know one.

but, i prefer to call my attitude "leadership qualities". i'm confident a lot of people who know me in the real world would agree. besides, i'm the most accomodating, helpful, pleasant, easy-going som' bitch you ever will meet... unless you try to (repeatedly) take advantage of me. give-and-take is a concept that partners have to understand. doing a portion of the "**** work" to pay your dues is understandable, but i've heard plenty of stories (and seen in the real world myself in my prior life) about how that quickly becomes "the norm" if you let it. a lot of people promise a lot of things, and i have plenty of attending friends who got f***ed on promises. get it in writing.

furthermore, it's hasn't been missed on me that the people in this thread now telling us how to "act" in our first jobs are also the ones currently holding all the cards.

so, no bitterness, dude. just another opinion. it's a well-accepted fact that most professional people have little concept how to be civil to each other, especially when large coin is involved. just look at the current mess that ineffective, unempowerment, "hoarding"-type management of CRNAs has gotten us into.

trust me. i'm not worried about MY attitude. i'll bust my balls if i'm rewarded commensurately. if not, there are other jobs. i'm flexible. and, there's always locums and academia (which so many of you seem to openly disdain)...
 
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furthermore, it's hasn't been missed on me that the people in this thread now telling us how to "act" in our first jobs are also the ones currently holding all the cards.
Click to expand...

How do you think they wound up "holding all the cards"?
 
.... "hoarding"-type management of CRNAs has gotten us into.
Click to expand...


Tell us more about this....I'm not sure what you are talking about.
 
militarymd said:
How do you think they wound up "holding all the cards"?
Click to expand...

yeah, and no one anymore thinks that hazing while joining a fraternity is acceptable. and, if people don't stand up to it, it always seems to get worse and worse with subsequent iterations.
 
VolatileAgent said:
are CRNAs able to become partners or at least have partnership rights (ie. some form of ownership) in your practice?
Click to expand...


We don't employ CRNAs....the hospital employs them.

There are practices that I know where CRNAs are part owners...along with the physicians.
 
okay, we are starting to address bigger issues here...

militarymd said:
We don't employ CRNAs....the hospital employs them.
Click to expand...

there's a big part of the problem right there.

militarymd said:
There are practices that I know where CRNAs are part owners...along with the physicians.
Click to expand...

i would argue that such practices are few and far between... and the "old paradigm" that a lot of these private practice "fiefdoms" have utilized for so long are going to eventually get swallowed by the tidal wave of "medical practice management" models that are cropping-up in every field of medicine.

i respect and agree with a lot of what jet said in his original post, but i've also thought a lot about this and have had a lot of "real world" experience to back-up my opinions. you don't adapt, you die.

this is a multi-fronted battle, and there are a lot of places where practices need to start getting a lot more creative in the way they manage themselves and the people who work for them, something they've been notoriously and historically bad at doing. we have to protect ourselves in our current practices, empower people who are going to be the future shepherds of our profession, and get more active and creative in how we do the business end of anesthesia. until then, the MBA/JD/bureaucrat creep that is dictating how we do a lot of what we do is going to continue to flourish, all while we remain preoccupied managing our little slice of self-interest within the small-world view we've carved out for our own little sphere of control. why, for instance, do you think i push so hard for people to contribute and be active in the ASAPAC?

no, the knee-jerk idea is that we up-and-coming professionals need to conform to an antiquated, hierarchical system just because "that's the way it's always been done" is ultimately going to f*ck us all down the road... if we let it.

in other words, i already have a five-year plan rife with a multitude of options. do you?
 
is ultimately going to f*ck us all down the road.
Click to expand...

You have NO idea how true this is.....except you just don't know where the fu cking is going to come from.
 
VolatileAgent said:
there is no fiduciary responsibility to you. has the psychological importance of that never crossed your mind? they are not "your" employees and/or partners.
Click to expand...

When you attend in the ICU or the CCU or the ward....are the nurses there YOUR employees?

Of course not....nurses of no fiduciary responsbility to me...and I don't want it. They have a responsbility to MY patients and to their employer.....the goal of which are the same....good patient care.

Do they need to be YOUR employees to be your nurse?

Of course not...That is just being silly....being a nurse is being a nurse....nurses have job descriptions which they fulfill.
 
VolatileAgent said:
so, let me more succinctly summarize: no one likes a slow, lazy, inept complainer. that's pretty much all you needed to say.

as one of those likely "egocentric" (i think you probably meant egotistical) residents you were referring to, i can also tell you this: don't be a doormat. all physicians - hell, all people - are ultimately egocentric, especially when it comes to their careers and family. you don't have to subrogate your rights to be the same way just because you are new employee (yes, you are just a worker bee when you start ANY job somewhere as "new blood" - heed jet's advice in that regard.)

this is the most important thing you said in your post:



it's your right - your responsibility - to say something. the problem arises is that some people are just simply clueless as to the appropriate way to seek redress for complaints. you have to do this cleverly and politically. if you can't, then keep your mouth shut and start looking for another job somewhere else. because, if you take that crap quietly, who do you think they are going to call next time? think about that...

so, i want to make this completely clear as well. if you ask by your actions to be **** upon by anyone in a practice, you will. the true "problem employee" is a rare thing despite what others may want to make you believe. if you show up and do what you're supposed to do when you're supposed to do it, you'll do fine. the job market right now dictates that. and, when the time is right, stand up for yourself and asked to be compensated appropriately. if it's becomes clear that you're not going to make partner, then it was already time to start looking somewhere else six months prior to that point.

so, be professional, be courteous, and be competent. you don't have to kiss anyone's ass to accomplish that, and you shouldn't. if you act like a doormat, you will get walked on.

trust me, i've got YEARS of real world experience behind me prior to going down this path. and, as someone who's about to graduate from my program, i'm having no problems finding a multitude of folks who are more than willing to pay for my services. play the game and play it well and you will thrive.



yes, true. but, easier said in an internet forum than done. but, never let someone else exploit your skills and talents.

so, in summary, yes, you might have to bite the bullet for a year or two to be in the practice and location you want to be, but if they start asking you to do bizarre things, treating you like ****, or taking advantage of you in any way, don't wait for that unexpected pink slip. hand them your resignation. there are plenty of other jobs out there right now.
Click to expand...



Just trying to offer (free) advice to residents out there after reflecting on my ten years of practice. My successes. My mistakes.

Take it or leave it.
 
VolatileAgent said:
okay, we are starting to address bigger issues here...



there's a big part of the problem right there.



i would argue that such practices are few and far between... and the "old paradigm" that a lot of these private practice "fiefdoms" have utilized for so long are going to eventually get swallowed by the tidal wave of "medical practice management" models that are cropping-up in every field of medicine.

i respect and agree with a lot of what jet said in his original post, but i've also thought a lot about this and have had a lot of "real world" experience to back-up my opinions. you don't adapt, you die.

this is a multi-fronted battle, and there are a lot of places where practices need to start getting a lot more creative in the way they manage themselves and the people who work for them, something they've been notoriously and historically bad at doing. we have to protect ourselves in our current practices, empower people who are going to be the future shepherds of our profession, and get more active and creative in how we do the business end of anesthesia. until then, the MBA/JD/bureaucrat creep that is dictating how we do a lot of what we do is going to continue to flourish, all while we remain preoccupied managing our little slice of self-interest within the small-world view we've carved out for our own little sphere of control. why, for instance, do you think i push so hard for people to contribute and be active in the ASAPAC?

no, the knee-jerk idea is that we up-and-coming professionals need to conform to an antiquated, hierarchical system just because "that's the way it's always been done" is ultimately going to f*ck us all down the road... if we let it.

in other words, i already have a five-year plan rife with a multitude of options. do you?
Click to expand...



Your points are interesting. I am curious as to why you asked the questions of allowing CRNAs to become partners?
 
VolatileAgent said:
as one of those likely "egocentric" (i think you probably meant egotistical) residents you were referring to, i can also tell you this: don't be a doormat. all physicians - hell, all people - are ultimately egocentric, especially when it comes to their careers and family. you don't have to subrogate your rights to be the same way just because you are new employee (yes, you are just a worker bee when you start ANY job somewhere as "new blood" - heed jet's advice in that regard.)
Click to expand...

Sorry if you took that egocentric thing personal, Volatile. Certainly unintended.

I didnt have any particular posters in mind when I wrote that. I do feel periodically that things are blown outta proportion periodically on this forum, and individuals tend to speak above their experience level.....

....point being, there are times to speak up and there are times to listen, even during situations where you are being (hopefully constructively) critisized. Being on a partnership track is the time to listen more times than not.

You mentioned "abuse"...yes, there are groups out there like that. Lets assume, though, that you've selected a reputable group that has a reputation for making new-hires partner as opposed to abusing them. Then re-read my initial post with that mindset as opposed to a cynical one.

I'm certainly no doormat. Nor is Mil. Noy. UT. You gotta pick your battles. And when it comes down to it, there arent alot of battles. It just seems that way if one chooses a cynical point of view all the time.

During my partnership track at my previous gig I said a few things in a few situations where, looking back, I wish I had just swallowed my pride/opinion. Hence my points concerning this in the initial post. Did it affect my partnership? Nope. Could it have? Yep.

I'll continue to post my opinions and suggestions.

Thats all they are.

Opinions and suggestions.
 
I have a question somewhat related to this topic. Are graduates of the smaller community hospital better prepared for private practice immediately after graudation, or are they in a similar boat with their academic counterparts?
 
jetproppilot;4182354 You mentioned "abuse"...yes said:
This topic has been mentioned several times in various posts recently. Im just a CA1 and a few years from the job search. But Id like to know how prevalant this abuse is, and how to avoid falling into these kinds of traps when heading out into the private world. What Ive gathered is avoid the management companies. But Im sure its much broader than that.

unfortunately very few responded to Mils recent posts about the types of practice options and there feelings. I would have liked to have seen more input.
Click to expand...
 
jetproppilot said:
Sorry if you took that egocentric thing personal, Volatile. Certainly unintended.

I didnt have any particular posters in mind when I wrote that. I do feel periodically that things are blown outta proportion periodically on this forum, and individuals tend to speak above their experience level.....

....point being, there are times to speak up and there are times to listen, even during situations where you are being (hopefully constructively) critisized. Being on a partnership track is the time to listen more times than not.

You mentioned "abuse"...yes, there are groups out there like that. Lets assume, though, that you've selected a reputable group that has a reputation for making new-hires partner as opposed to abusing them. Then re-read my initial post with that mindset as opposed to a cynical one.

I'm certainly no doormat. Nor is Mil. Noy. UT. You gotta pick your battles. And when it comes down to it, there arent alot of battles. It just seems that way if one chooses a cynical point of view all the time.

During my partnership track at my previous gig I said a few things in a few situations where, looking back, I wish I had just swallowed my pride/opinion. Hence my points concerning this in the initial post. Did it affect my partnership? Nope. Could it have? Yep.

I'll continue to post my opinions and suggestions.

Thats all they are.

Opinions and suggestions.
Click to expand...

Prior to med school I worked in corporate america - in consulting for a few years. Over that time I worked my way up the ladder quickly, quicker than anyone else there. Not saying I am such a wonderful person or anything, but I was at least in some respect successful (if only medicine was as easy as business). The things I learned a long the way was pretty much exactly what Jet was talking about. Being FLEXIBLE, not making a big deal when a senior consultant takes all week to do his portion of the presentation and emails it to you friday afternoon for you to add your part. His part is finished. When Mr. Partner-Boss finds out that things didnt get done, the guy who just f-ed you can still say that he got his part done in time. So you suck it up. You complete your analysis, add your slides, change all the slides before it that are now irrelevant because they didn't look at the big picture, as well as a few hours of thankless formatting cause your the last guy to get the presentation - which takes you all weekend, AND you have to fly to San Deigo Sunday night to give the presentation with the other consultants. Don't bich about it, just do it. If that particular consultant does it EVERYTIME and theres a pattern of abuse compromising the quality of product your delivering, then you can make an issue of it. If it happens every now and then, suck it up. Be the clutch guy. Be INVAULABLE. Meet every timeline. If it is out of your control, don't cry to the Partners, call the client and work something out, then call the partners. Get things done in a timely fashion. Some times people will notice. Sometimes they won't. But eventually someone will fuigure out that when youre one of the consultants on the team, things go smoother. Then they want you to manage a few small projects. Those go well, manage some bigger ones. Then gain the title of senior consultant before your 30 years old, make good bank, and if your a ***** quit and go to med school.

Anyway, point being the essence of what Jet said, if not simply common sense, is more about how to do well in any business environment, just not a group practice. And what Volatile says is also very true - if you have someone that takes advantage of you over and over and you don't change it, it will continue to happen. But you need some street cred first, or you'll get labeled a complainer, or even worse, difficult to work with.

I guess my main point, if I even have a point, is that everything Jet was saying is no different in business (at least a small business model) and, even more importantly, just really makes a lot of sense.
 
But you need some street cred first, or you'll get labeled a complainer, or even worse, difficult to work with.
Click to expand...

My point....a new grad who is not board certified...for the most part, with exceptions, has no "creds".
 
jetproppilot said:
During my partnership track at my previous gig I said a few things in a few situations where, looking back, I wish I had just swallowed my pride/opinion. Hence my points concerning this in the initial post. Did it affect my partnership? Nope. Could it have? Yep.
Click to expand...

Boy did I as well.
The idea of this thread is that you have a few veterans here that have "been there done that" and are attempting to make things easier for you guys. Just the fact that Jet has posted this shows the amount of respect he has for you guys/gals.

One thing that really gets me is when a resident (no one in particular here) thinks he or she should be treated equal when joining a new practice. You can expect less money, less vacation and therefore more call since you are on vacation less often. Other than that you should be treated pretty much the same day to day. Even distribution of cases, etc. If you complain too much you can expect to pay for it. The reason you are not equal is because while these guys were bustin their asses making a name for themselves and building a successful group you were not there helping out. You (no one in particular here) are not board certified. You have not yet proven yourself. And there is no real way to tell how you will fit in to the group. So what I am saying is expect to be treated differently in teh begining. Everyone has a certain amount of abuse (for lack of a better term but don't think of it as abuse in the real sense) that they can take. Everyone has their breaking point. If you have reached yours then stop to think, "did I bring this abuse on mself by my actions or is this group a bunch of assh*les"? Think of it as paying back your future partners for all the hard work they have done for you in the past b/4 you joined their group. Be grateful that they chose you and are giving you the opportunity to benefit from their sweat and tears.
 
props to the propmaster for the great post jet.

i think attitude is the cornerstone to success. thank you for bringing that into focus in your post.

having that "i am part of the solution" attitude is not as easy to find as one thinks in an employee.

peace...
 
I don't know that all management companies are bad. I was offered a good contract by one of them and I passed it by several of the senior members on this board. They agreed that it was a pretty good and fair contract. I didn't end up accepting it, but I thought it was fair too. That said, I did sign with another practice in GA and, even though it's an employed position, I am quite happy with my deal! The only tough part is that I have to wait 9 months to start!

Thanks for all of the advice guys...

Regards,
PMMD

usnavdoc said:
This topic has been mentioned several times in various posts recently. Im just a CA1 and a few years from the job search. But Id like to know how prevalant this abuse is, and how to avoid falling into these kinds of traps when heading out into the private world. What Ive gathered is avoid the management companies. But Im sure its much broader than that.

unfortunately very few responded to Mils recent posts about the types of practice options and there feelings. I would have liked to have seen more input.
Click to expand...
 
militarymd said:
When you attend in the ICU or the CCU or the ward....are the nurses there YOUR employees?

Of course not....nurses of no fiduciary responsbility to me...and I don't want it. They have a responsbility to MY patients and to their employer.....the goal of which are the same....good patient care.

Do they need to be YOUR employees to be your nurse?

Of course not...That is just being silly....being a nurse is being a nurse....nurses have job descriptions which they fulfill.
Click to expand...

Good point.
 
militarymd said:
Of course not....nurses of no fiduciary responsbility to me...and I don't want it. They have a responsbility to MY patients and to their employer.....the goal of which are the same....good patient care.
Click to expand...

a'ight man, sounds like you got it all figured out. just keep doing what you're doing in your practice. good luck.

and, next time you see one of your crna colleagues, be sure to remind them that they are just a "nurse".
 
VolatileAgent said:
a'ight man, sounds like you got it all figured out. just keep doing what you're doing in your practice. good luck.

and, next time you see one of your crna colleagues, be sure to remind them that they are just a "nurse".
Click to expand...


Sounds like you're insulting me......what's up with that?

I don't have it ALL figured out...If I did, I wouldn't be working......I wouldn't be continually evaluting the anesthesia market...trends...anesthesia models...etc.

Nurses are nurses....they don't need to be reminded of that....and calling someone a nurse is not an insult that you seem to think it is.....it is just a job description.....some nurses are highly trained and others are not.

So lets get back on track....

Why do nurses who take care of my patients....or for that matter...any other doctor's patients.....need fudiciary responsiblity to me or that doctor?

And..the other point...why is it bad for the hospital to employ CRNAs? Do hospitals not employ other nurses?

Are you saying that ALL physicians should employ their own nurses? so that there will always be a fudiciary responsbility to you the physician?

What are you trying to say?
 
VolatileAgent said:
a'ight man, sounds like you got it all figured out. just keep doing what you're doing in your practice. good luck.

and, next time you see one of your crna colleagues, be sure to remind them that they are just a "nurse".
Click to expand...

I'd like to address your bitterness toward the "nurse" issue but I don't want to hijack my own thread, which was started in the first place to try and HELP you. Not to insult you, not to empower one group or the other, not to say who is right and who is wrong. Not even to justify the "partnership" pathway....like it or not, private groups are still a dominant model in this industry. I know how they work. I know the process. You wanna go into private practice in the next ten years? Then I can assure you the advice in my initial post is good advice.

No ulterior motive/cynacism on my part.

Just some healthy, solid words from someone who's been where you havent: private practice anesthesia.
 
I must agree with Jet and Mil on this one, Volatile. While I understand your feelings towards the crna's to some degree, I must say that your view of them will more than likely change once you enter the real world. I also was fearful of their position in anesthesia when I was a resident not that long ago. They would take every opportunity to put down Dr's (the one's in academia) and claim their equality but once I entered PP I began to work with them in a team model and realized that the ones in the trenches were very content with their position on the team. A very few were confrontational, mostly the young ones who were recently trained. If you treat them poorly they will certainly make your life miserable at every opportunity.

Yes they are nurses but not "just" a nurse. They specialty nurses with advanced training.
 
oooh... the sharks smell blood... :scared: :laugh:

it is this simple:

1) crna's are NOT just nurses. you know this, mil. and, i find it intellectually dishonest for you to play this little word game on this thread. you know that they are mid-level practitioners who perceive themselves as being more than just a nurse. you know they are, in no hidden way, continuing the fight for independent practice rights. you know they have their own lobby pushing for this. you see their twisted, selfish logic in trying to deny 1:1 medicare reimbursement at academic centers. many want your job (and pay) and they don't want you around... they don't believe they need you around, and they are continously building their ranks to meet this goal. will this ulitmately happen? doubtful. but, where does this come from? money. exclusion. the sense of being an advanced practitioner and still be treated as "just a nurse". (and, i'm the one who has an attitude problem? 🙄)

2) the practice management environment is changing the field of medicine. if you think you can blow-off that fact, you are either ignorant of what's going on outside your own little realm or you don't care. look at pmichaelmd's post about taking a job at a practice management company. yes, MBA's will be telling you what to do someday, deciding what equipment you will buy, when you will work, etc. don't think this will happen? okay. lay your bets on the table.

the point is, the "old paradigm" is going to get crushed... if you don't adapt and change. these practice management groups will hire both crna's and md/do anesthetists. they will offer them the tracks and flexibility that they want (e.g., the female MD anesthesiologist who, just maybe, doesn't want to take call and isn't all that interested in becoming a partner, the crna who wants a sharehold stake in the piece of the pie at the end of the fiscal year, etc.). they will do a much better job of accomodating these people. and, you know what? they will also bargain for better contracts at the hospitals you're currently practicing at. they will be public companies offering stock/shares. they will be more creative, more flexible, more streamlined. they will have lower overhead. they will replace you.

don't believe that this can happen? i've seen it firsthand. i saw it destroy independent oncology practices back in the mid '90s. ( http://www.usoncology.com/Home/ ) and, many of the ppm models that took a hit in the late nineties (mostly from too-rapid growth and mismanagement) is going to make a resurgence, and is already starting with groups like wellspring. so, what are you doing to prevent this from happening again? can you prevent this from happening? the anesthesia-delivery model is RIPE for this kind of take-over.

so, you can continue to do things the way you've always been doing them, or you can adapt. it may not happen next year... it may not happen in the next five years... but, there is going to be a big change in the way we do the business end of this business. you admit so much above.

but, if you want to keep playing these little semantic games about crna's just being "nurses", go right ahead. i know that YOU know i have a point, and now you're either just trying to play some little game or save face. i know you're a smart, proven, practicing attending. and, i know you can see the roiling waters. our profession is getting squeezed on all sides. so, you can continue to do what you've always done and hope for the best, or you can invite "the enemy" into your home, actually include him and give him a share of the pie, and actually begin to take back control of what is now slipping away.

if the guys in your practice don't/can't see the potential for this happening, believe me when i tell you that there are groups out there who do. adapt or die.
 
militarymd said:
.....So lets get back on track....

1)Why do nurses who take care of my patients....or for that matter...any other doctor's patients.....need fudiciary responsiblity to me or that doctor?

2) And..the other point...why is it bad for the hospital to employ CRNAs? Do hospitals not employ other nurses?

Are you saying that ALL physicians should employ their own nurses? so that there will always be a fudiciary responsbility to you the physician?

What are you trying to say?
Click to expand...

Hey Volatile,

You're getting on a soapbox and straying off topic here........You're spouting off about a whole bunch of stuff.....you're obviously bitter about something, but I'm not sure what...and I think you're not sure either...

Now, I'm kind of older...and SLOWER about these things....the old boy southern living must be slowing me down....

The above 2 things you said.....Can you clarify? I've asked you to clarify a few times already, but you keep getting upset and stray off topic.

Can you answer the above 2 questions?
 
jetproppilot said:
I'd like to address your bitterness toward the "nurse" issue but I don't want to hijack my own thread, which was started in the first place to try and HELP you.
Click to expand...

if you sincerely believe this is the crux of my posts, you've completely missed the point, jet. i have no bitterness towards crnas. quite the contrary. i think we need to begin to do a better job of including them in our practices, which will serve a multitude of goals (some financial, some psychological) that will make everyone's life easier and happier. and, i've got a pretty clear, simple way to do this based on past professional experience. but, many of you just seem only to want to lecture me on "the way it should be done."
 
va said:
1) crna's are NOT just nurses. ......they are mid-level practitioners who perceive themselves as being more than just a nurse. you know they are, in no hidden way, continuing the fight for independent practice rights......
Click to expand...

ummm ...certified registered NURSE anesthetist.....It really doesn't matter how they view themselves...it's how the physicians view them that counts. They can lobby for anything they want....but ultimately it is what the MEDICAL STAFF of the hospital that decides who gets to do what.....

I don't know...seems like having them as hospital employees is the way to go.


va said:
2) the practice management environment is changing the field of medicine. if you think you can blow-off that fact, you are either ignorant of what's going on outside your own little realm or you don't care. look at pmichaelmd's post about taking a job at a practice management company. yes, MBA's will be telling you what to do someday, deciding what equipment you will buy, when you will work, etc. don't think this will happen? okay. lay your bets on the table.
Click to expand...

Where the hell did this come from? When did we start talking about management groups? There are multiple models/business arrangements of providing anesthesia....the one that gets the contract is the one that provides the BEST service for the LEAST cost....that's life...that's business...it has always been that way...it will always be that way....

dinosaur models become extinct....pig models get slaughtered....lion models win the contract and fu ck the cheerleaders..and get to decide who becomes partners.....

EVERYONE knows that....I assume when you're talking about practice managment companies.....you know you're talking about things that those of us actually in practice having been dealing with for the last 10 years already.

va said:
the point is, the "old paradigm" is going to get crushed...
Click to expand...

There is no old or new paradigm....it's always been the same...see above....

va said:
they will have lower overhead. they will replace you.
Click to expand...

What world do you live in? Practice management companies.....by definition will ALWAYS for HIGHER overhead....they have to pay managers who don't do clinical work......They replace groups by providing a better service...They always cost the hospital more money.
 
VolatileAgent said:
furthermore, it's hasn't been missed on me that the people in this thread now telling us how to "act" in our first jobs are also the ones currently holding all the cards.
Click to expand...

militarymd said:
How do you think they wound up "holding all the cards"?
Click to expand...

VolatileAgent said:
yeah, and no one anymore thinks that hazing while joining a fraternity is acceptable. and, if people don't stand up to it, it always seems to get worse and worse with subsequent iterations.
Click to expand...


Here's another string....How do you think all those guys wound up holding all the cards.
 
militarymd said:
Hey Volatile,

You're getting on a soapbox and straying off topic here........You're spouting off about a whole bunch of stuff.....you're obviously bitter about something, but I'm not sure what...and I think you're not sure either...

Now, I'm kind of older...and SLOWER about these things....the old boy southern living must be slowing me down....

The above 2 things you said.....Can you clarify? I've asked you to clarify a few times already, but you keep getting upset and stray off topic.

Can you answer the above 2 questions?
Click to expand...

well, first off, i'm sure i'm older than you. but, just so we're clear, grandpa...

1)Why do nurses who take care of my patients....or for that matter...any other doctor's patients.....need fudiciary responsiblity to me or that doctor?
Click to expand...

1) again, we can't get past this point if you are going to continue to intellectually dishonestly equate a crna with a floor nurse. and, it is not a question of need, mil. it is a question of providing a superior reimbursement/ownership structure to someone who believes - right or wrong - that they provide a higher level of direct decision-based treatment to a patient. in that sense, they already feel you are redundant. so, it is more about having direct fiduciary relationship by bringing them into your group, providing them a superior financial and professional incentive to be loyal to your practice and not to the hospital. it has nothing to do with the ethical responsibility to the patient, a red herring you are trying to introduce which is irrelelvant. anesthesiology is unique in that, during a case, a crna provides one-to-one care with a patient SOLELY under the physician's direction who is often not present. furthermore, a lot of minute-to-minute decisions are made without the physician's consultation. so, to continue to insinuate that crna's are "just another nurse" who are under the direction likewise, the concept that these are "your" patients, in this context, is also antiquated and irrelevant. you are a consultant. you are providing a safe environment for surgery to proceed. crna's believe that they can do an equal job to you in most cases, in that regard (again whether that is actually true or not is irrelevant in the perception of things).

2) And..the other point...why is it bad for the hospital to employ CRNAs? Do hospitals not employ other nurses?
Click to expand...

2) where did i ever say it was "bad" for the hospital to employ crnas? it is probably very good for the hospital to do so, and practices like yours are allowing them to do it. so, don't put words in my mouth. but, is there possibly a superior way that allows physician-based practices more control over who's providing the care? of course. you admit certain practices are already doing this. likewise, is there a better way to placate an empowered, politically-active group who - on a national policy level - seeks to minimize and marginalize the role of the anesthesiologist? absolutely. so, why aren't we doing this? just so we're clear, mil, no one - certainly not i - suggested that it's "bad" (whatever that means) for hospitals to employ crnas except you. personally, i think it's stupid that you allow it, though. i have offered that the "old way" of doing things is going to change over the next 5-10 years whether you like it or not, and that the anesthesia delivery model is a VERY easy place for PPMCs to come in and streamline what you do, especially if the CRNAs win and don't need us around anymore for the bulk of the cases that are routinely done. so, again, mil, if you want to keep equating crna's to "other nurses", we just can't continue to have this conversation.
 
VolatileAgent said:
anesthesiology is unique in that, during a case, a crna provides one-to-one care with a patient SOLELY under the physician's direction who is often not present. furthermore, a lot of minute-to-minute decisions are made without the physician's consultation. so, to continue to insinuate that crna's are "just another nurse" who are under the direction likewise, the concept that these are "your" patients, in this context, is also antiquated and irrelevant.
Click to expand...

I believe you need to spend more time working in the ICU if you think what you just posted is true.....

and I mean private practice ICUs....not the IVory tower ones that you did your 2 month stint......
 
VA said:
is there a better way to placate an empowered, politically-active group who - on a national policy level - seeks to minimize and marginalize the role of the anesthesiologist? absolutely. so, why aren't we doing this?
Click to expand...

You are confusing REIMBURSEMENT laws, SCOPE OF PRACTICE laws, etc....with what ACTUALLY happens at individual hospitals...

Congress can pass any laws that it wants....Medicare can pass any reimbursement rules it wants....

What a nurse is allowed or not allowed to do at each hospital is DICTATED by the MEDICAL STAFF....which has ZERO to do with all the things that seem to concern you .....

The ONLY reason that nurse anesthetists have independent practice at various hospitals is because the MEDICAL STAFF has ALLOWED.

Don't confuse MEDICAL STAFF BYLAWS with what happens in politics.

CRNAs have independent practice rights already in the vast majority of states....but they don't in the vast majority of states....

Do you know why? It's not because of the laws.....it's because of the MEDICAL STAFF bylaws....which, by the way, were passed and maintained by the anesthesiologists who were there (the ones holding the cards) before the young ones coming up.
 
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