AANA’s Latest Tweets

[coffeebythelake]

Problem with this BS “collaborative model” is 2 fold. 1) the docs are going to get dumped on with all the cases the CRNAs can’t handle. 2) what is the legal liability if a doc happens to be free and has to lend a second pair of hands in one of the CRNA rooms? I’m comfortable doing this for my partners because they’re not incompetent. Who knows what you’re going to walk into with a CRNA room where there has been zero physician input or involvement?

I'd want to let them struggle, but that wouldn't be in the patient's best interest

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[GA8314]

Agreed. But, I only use the "collaborative model" as just one example of a morphology that things could take. I just think that it is absolutely not inevitable that our ratios go further than 4:1. If we see massive sea change in anesthesia delivery then there are numerous ways in which this could evolve. Maybe we will see many different models?

Our field is still a well compensated one. Keep your skills and you will have a good career. Yes, medicine is changing, but if you stay close to the patient you will have a job. Not all trends are positive, but not all are negative. Too much doom and gloom on here, IMO.

10 years ago it looked like AMC's were taking over the field. Now we see they are losing momentum in a pretty substantial way. It just seems that we can't really say what will be inevitable or not.

Meantime, we go in and do our jobs and earn a decent living. I'm not saying not to worry. It's good to advocate, but we need to realize our own levels of neuroticism can work against us in some ways.

 

[Man o War]

Agreed. But, I only use the "collaborative model" as just one example of a morphology that things could take. I just think that it is absolutely not inevitable that our ratios go further than 4:1. If we see massive sea change in anesthesia delivery then there are numerous ways in which this could evolve. Maybe we will see many different models?

Our field is still a well compensated one. Keep your skills and you will have a good career. Yes, medicine is changing, but if you stay close to the patient you will have a job. Not all trends are positive, but not all are negative. Too much doom and gloom on here, IMO.

10 years ago it looked like AMC's were taking over the field. Now we see they are losing momentum in a pretty substantial way. It just seems that we can't really say what will be inevitable or not.

Meantime, we go in and do our jobs and earn a decent living. I'm not saying not to worry. It's good to advocate, but we need to realize our own levels of neuroticism can work against us in some ways.

I agree with you completely.

 

[coffeebythelake]

I have no doubt that we will still have jobs, and even great jobs even with the current political climate and the direction medicine is going. We have the skills and training unsurpassed by any other. We are just hating against the CRNAs who think they can do the same or better job than us. They will never replace us no matter what they think

 

[pgg]

Problem with this BS “collaborative model” is 2 fold. 1) the docs are going to get dumped on with all the cases the CRNAs can’t handle. 2) what is the legal liability if a doc happens to be free and has to lend a second pair of hands in one of the CRNA rooms? I’m comfortable doing this for my partners because they’re not incompetent. Who knows what you’re going to walk into with a CRNA room where there has been zero physician input or involvement?

You're not wrong but it's the best of a set of bad outcomes.

This "collaborative" model is what we have in the military. It's also what I worked in as a locums moonlighter in a rural part of California.

It's true that the low hanging fruit / chip shot cases are triaged to the CRNAs. (This is just one more false side of the AANA's "independence" lies. We know they're not independently caring for all of comers.)

I can see how this might be undesirable to some anesthesiologists - there's certainly some enjoyment and satisfaction to doing a low risk easy case by yourself, and I do enjoy the rare day spent doing lap choles and hernias by myself.

Is there really lower risk, though? I think it's worth making a distinction between a high risk patient and a high malpractice risk case - the two aren't all that congruent. The aged septic vasculopath with a SBO is at high risk for a bad outcome but not really a lawsuit. The 12 year old chubby kid getting a tonsillectomy ...

The really scary legal risk is in doing cases that should go well while practicing "at the top of one's license" ... that's the CRNA's nightmare, not ours.



As for the legal risk of being uninvolved in a case and showing up to help with crisis management - this fear seems to be ungrounded. It's not like this is unknown territory. Every person who responds to a code, every surgeon who scrubs in to help out a colleague, every consultant who walks into a ****show someone else started - none of these people are getting held responsible for mistakes that were made prior to their arrival.

 

[IlDestriero]

Problem with this BS “collaborative model” is 2 fold. 1) the docs are going to get dumped on with all the cases the CRNAs can’t handle. 2) what is the legal liability if a doc happens to be free and has to lend a second pair of hands in one of the CRNA rooms? I’m comfortable doing this for my partners because they’re not incompetent. Who knows what you’re going to walk into with a CRNA room where there has been zero physician input or involvement?

You have NO idea. I used to see it all in the Navy. One peds surgeon refused to allow them in his room at all. Some of their plans for complex patients were just plain stupid. Weird things they insisted on doing that introduced the potential for problems, etc. One of my first call duties was to check all the rooms and see if one of the CRNAs would “get to go home early” when they were grossly mismanaging a (not so) “big” case. Seriously. And surprise, they never said, “No thanks man, I’ll finish it up.”
Also the hand charted vitals and the ones you pulled up on the monitor were often quite different. I guess to some 90/50 with a MAP of 63 and 80/40 with a MAP of 53 are close enough to just round up to a MAP of around 70. Tachycardia for hours in the old patient, no problem. Right?
This was a regular thing. They start out behind and then get experienced in being complacent because most people do just fine immediately post op. Then they get lazy and ignore everything that’s not an acute decompensation.


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Il Destriero

 

[ProRealDoc]

No, the trend absolutely does not need to be one of a firefighter. This is precisely why I will NEVER allow my "monkey skills" to atrophy. Because when you maintain your monkey skills, you will always have a job. You may make less, but I (and I'm in a 90% supervision model) would argue that most of us in ACT models would take a 100k pay cut for the stress reduction and greater professional satisfaction of doing our own cases.

The end game for us may be "collaborative" and we can see how reimbursements go from there, but I submit that you can make a GOOD living sitting your own cases, and that the future need not be greater than 4:1. Indeed, I do not feel that I am alone in being willing to take a 30% pay cut if ratios were to grow beyond 4:1.

Also, do you realize how desperate administrations are to relinquish employment of their precious CRNA's?? They can't dump them onto us fast enough. Or onto an AMC..... We employ the CRNA's at my shop. We docs in my practice are not at risk of a job, but if we transitioned to a collaborative model (which we can all agree is the end game of the AANA, ,so in other words if the AANA gets their way entirely), then we would need LESS CRNA's not more.

For the juniors out there. I can say this because I eliminated my debt in less than 5 years post graduation. I strongly recommend you do this. It gives you a sense of freedom, and I am serious when I say I would take 100k LESS if the BS factor get's too big. I am quite certain I would enjoy my day much more this way, barring endoscopy....

Also, when you look at FTE data, you will see that for 40 hours per week, we are not THAT much over what a CRNA cost is. So, perhaps the beancounters will recognize a different dynamic in this area as well. But, no, the "future" is not one of "firefighters". Some groups may choose to go this way, but the market will then shift in other ways.

We are a neurotic bunch in medicine. But, the sky is not falling.

I actually saw this first hand in my practice. Hospital was sick of dealing with the constant whining and pay increase demands made by CRNAs so much so that they stopped talking to them. Now they are employed by us.

 

[Man o War]

You have NO idea. I used to see it all in the Navy. One peds surgeon refused to allow them in his room at all. Some of their plans for complex patients were just plain stupid. Weird things they insisted on doing that introduced the potential for problems, etc. One of my first call duties was to check all the rooms and see if one of the CRNAs would “get to go home early” when they were grossly mismanaging a (not so) “big” case. Seriously. And surprise, they never said, “No thanks man, I’ll finish it up.”
Also the hand charted vitals and the ones you pulled up on the monitor were often quite different. I guess to some 90/50 with a MAP of 63 and 80/40 with a MAP of 53 are close enough to just round up to a MAP of around 70. Tachycardia for hours in the old patient, no problem. Right?
This was a regular thing. They start out behind and then get experienced in being complacent because most people do just fine immediately post op. Then they get lazy and ignore everything that’s not an acute decompensation.


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Il Destriero

I believe it, absolutely insane.

 

[Man o War]

You're not wrong but it's the best of a set of bad outcomes.

This "collaborative" model is what we have in the military. It's also what I worked in as a locums moonlighter in a rural part of California.

It's true that the low hanging fruit / chip shot cases are triaged to the CRNAs. (This is just one more false side of the AANA's "independence" lies. We know they're not independently caring for all of comers.)

I can see how this might be undesirable to some anesthesiologists - there's certainly some enjoyment and satisfaction to doing a low risk easy case by yourself, and I do enjoy the rare day spent doing lap choles and hernias by myself.

Is there really lower risk, though? I think it's worth making a distinction between a high risk patient and a high malpractice risk case - the two aren't all that congruent. The aged septic vasculopath with a SBO is at high risk for a bad outcome but not really a lawsuit. The 12 year old chubby kid getting a tonsillectomy ...

The really scary legal risk is in doing cases that should go well while practicing "at the top of one's license" ... that's the CRNA's nightmare, not ours.



As for the legal risk of being uninvolved in a case and showing up to help with crisis management - this fear seems to be ungrounded. It's not like this is unknown territory. Every person who responds to a code, every surgeon who scrubs in to help out a colleague, every consultant who walks into a ****show someone else started - none of these people are getting held responsible for mistakes that were made prior to their arrival.

I’m actually the least worried about getting sued now than I’ve ever been, and am treating by far on average the sickest patients I’ve ever had.
The 80 year old cardiac patient’s family likely won’t sue you. The 30 year old’s family who dies during birth will.
@pgg were the docs in the collab model who were picking up the hard cases getting paid significantly more than the CRNAs getting the easy ones?
I am still really uncomfortable with assuming care of a patient from a mid level who screwed the pooch from a legal standpoint when I was not even involved in the plan from the jump. What is the point of this “collaborative model” if not to have a doc around to absorb some liability?
What if a CRNA “collaborates” with me before a case they are unsure of and documents it in the chart, and something goes wrong? I’m definitely getting deposed at minimum in both situations I think.
Why not just work independent of each other instead of collaboratively?
This is way too much of a gray area IMO.

 

[skypilot]

I’m proud of my “monkey skills”. Its taken me
many years of practice, refining, and on going learning to get where I am...and I’m not done. If you were to ever bring your little monkey to my neck of the woods, I’d be proud to offer my monkey skills to help them...Now, I’ve seen first hand many CRNA/AA to foul up challenging airways, create hematomas where PIV/A-lines/Neuraxial should go because they either asserted themselves where their skills lacked or their attending put them in situations beyond skill-set. Could they get better with more practice- of course. But why should I sit back and let them practice on your kid when I am right there? Does that make me a poor team player? When I’m medically directing, I see myself as a player/coach, and my job as leader of the team is to get the right people in the right places to succeed. Does the backup QB get to play when the game is on the line- heck no! In my practice , I try to put the patient’s needs/safety first, and I’ll be damned to let some CRNA/AA hone their monkey skills while mine get rusty, just for their personal satisfaction. The delegation of these procedures may occur but not at the expense of safety and quality of patient care. At my shop, where we are either solo (yay) , 2:1, 1:1, and rarely 3:1, it just doesn’t make sense to delegate many of these monkey skills. Yet many of my colleagues do and I get to see some real scary stuff. I also get to see many attendings struggle on basic monkey skills - hmm, ya think there is a correlation with (over)delegation of procedures and mediocre competency of these monkey skills? I know that as anesthesiologists we are not defined by “monkey skills” but we can’t just be decision makers and delegators either. I’m proud to do both.
In a practice where you’re more spread thin, then I can understand the economics driving the mid-levels doing these monkey skills, but God help me, don’t let me be in one of those practices- and what happens when YOU’RE called upon to save them- will you be ready when Seconds Count?

This is great. And we forget how long it took to get really reflexive with these skills.... years. And we forget how valuable and how skilled we really are, and how very simple moves can make the difference between a sick patient heading to the ICU, and a sick patient heading to the floor after surgery.

 

[pgg]

@pgg were the docs in the collab model who were picking up the hard cases getting paid significantly more than the CRNAs getting the easy ones?

Yes. It was a physician owned and run group that employed the CRNAs. There was a sizable subsidy from the hospital because the BFE units were terrible. The CRNAs did a fair amount of call and overtime. They were making something in the $200s. I made about $10K per (50-60 hour) week of locums there, give or take.

At the time I was trying to decide if I should get out of the Navy or stick out some more time for the pension. The offer I had to get out and stay there was somewhere around $400K 1099 for a mostly outpatient job, 100% doing my own cases. No trauma, OB, hearts, or heads. We never got to the point of discussing specifics. They were a little vague about the partner track, the subsidy concerned me, another partner-but-not-really-a-partner had just unhappily left minus the buyout he thought he was due ... and in any case the math worked out strongly in favor of staying in the Navy.

I am still really uncomfortable with assuming care of a patient from a mid level who screwed the pooch from a legal standpoint when I was not even involved in the plan from the jump. What is the point of this “collaborative model” if not to have a doc around to absorb some liability?

Is that really any different than responding to a code somewhere in the hospital after a nursing assistant, RN, midlevel, or other doctor screwed the pooch?

The points are
1) cover 5 rooms with 5 people instead of 4 with a 4:1 ACT model
2) minimize M&M by triaging sick/complicated cases to anesthesiologists
3) advise the CRNAs if they feel they need it, despite the triage
4) rarely, floorwalker / preop guy can just do the case with the CRNA 1:1
5) firefighting

There was enough low hanging fruit to keep the CRNAs well within their comfort zones so 3 & 4 & 5 were uncommon events.

It was more troublesome on call. Most nights there was a 1st call CRNA and 2nd call anesthesiologist. When I was #2, I got called quite a few times by the 1st call CRNA if he was uncomfortable or if the surgeon asked for MD anesthesia. I would just go in and do the case.

What if a CRNA “collaborates” with me before a case they are unsure of and documents it in the chart, and something goes wrong? I’m definitely getting deposed at minimum in both situations I think.

If you advise them / "collaborate" on a plan, and the plan is appropriate, your exposure is probably low. Not zero, but low.

Also, this was pretty unusual. They were triaged to cases specifically so they wouldn't be uncomfortable and unsure. If a case came about where they were unsure, often the schedule was adjusted so that an anesthesiologist would just do the case (e.g. the call scenario above). Sometimes the anesthesiologist would just do the case with the CRNA.

The bottom line is that the great majority of the time there'd be zero contact between the CRNA and any of the anesthesiologists. When there was "collaboration" or help needed, the anesthesiologist was in charge and it was essentially 1:1 ACT model for that case.

Why not just work independent of each other instead of collaboratively?
This is way too much of a gray area IMO.

I see your points, but honestly the "collaboration" was mostly an anesthesiologist telling the CRNAs "you're going to go do these cases today, call if you have questions or need something" and then rarely getting called.

When called, it morphed into something akin to a short-lived 1:1 ACT practice for the duration of a case.


In my military practice, it's much the same, just with better liability insurance, and an explicit requirement for them to discuss all ASA 3 & 4 patients with one of us.


To be clear, I favor a model where anesthesiologist direction of CRNAs happens for every case. But that ship has sailed. For selfish non-patient-centric reasons, I'd rather work in one of these "collaborative" models than run around in a 4:1 ACT. Done both; the "collaborative" workplace is worlds easier.

 

[pgg]

You have NO idea. I used to see it all in the Navy. One peds surgeon refused to allow them in his room at all. Some of their plans for complex patients were just plain stupid.

We just don't assign them to those rooms or cases in the first place. Every once in a while a CRNA will get a healthy kid in their room. But the peds surgeons don't spend much time with CRNAs.

Also the hand charted vitals and the ones you pulled up on the monitor were often quite different. I guess to some 90/50 with a MAP of 63 and 80/40 with a MAP of 53 are close enough to just round up to a MAP of around 70. Tachycardia for hours in the old patient, no problem. Right?

I've seen lots of anesthesiologists put, uh, "subjective" vitals on paper too. The paper vs computer chart discrepancies are widespread. One of the things I love about EMRs. The chart is reliable.

 

[skypilot]

To be clear, I favor a model where anesthesiologist direction of CRNAs happens for every case. But that ship has sailed. For selfish non-patient-centric reasons, I'd rather work in one of these "collaborative" models than run around in a 4:1 ACT. Done both; the "collaborative" workplace is worlds easier.

Yes, I agree. But I am ashamed to admit it.

 

[GravelRider]

Yes. It was a physician owned and run group that employed the CRNAs. There was a sizable subsidy from the hospital because the BFE units were terrible. The CRNAs did a fair amount of call and overtime. They were making something in the $200s. I made about $10K per (50-60 hour) week of locums there, give or take.

At the time I was trying to decide if I should get out of the Navy or stick out some more time for the pension. The offer I had to get out and stay there was somewhere around $400K 1099 for a mostly outpatient job, 100% doing my own cases. No trauma, OB, hearts, or heads. We never got to the point of discussing specifics. They were a little vague about the partner track, the subsidy concerned me, another partner-but-not-really-a-partner had just unhappily left minus the buyout he thought he was due ... and in any case the math worked out strongly in favor of staying in the Navy.




Is that really any different than responding to a code somewhere in the hospital after a nursing assistant, RN, midlevel, or other doctor screwed the pooch?

The points are
1) cover 5 rooms with 5 people instead of 4 with a 4:1 ACT model
2) minimize M&M by triaging sick/complicated cases to anesthesiologists
3) advise the CRNAs if they feel they need it, despite the triage
4) rarely, floorwalker / preop guy can just do the case with the CRNA 1:1
5) firefighting

There was enough low hanging fruit to keep the CRNAs well within their comfort zones so 3 & 4 & 5 were uncommon events.

It was more troublesome on call. Most nights there was a 1st call CRNA and 2nd call anesthesiologist. When I was #2, I got called quite a few times by the 1st call CRNA if he was uncomfortable or if the surgeon asked for MD anesthesia. I would just go in and do the case.




If you advise them / "collaborate" on a plan, and the plan is appropriate, your exposure is probably low. Not zero, but low.

Also, this was pretty unusual. They were triaged to cases specifically so they wouldn't be uncomfortable and unsure. If a case came about where they were unsure, often the schedule was adjusted so that an anesthesiologist would just do the case (e.g. the call scenario above). Sometimes the anesthesiologist would just do the case with the CRNA.

The bottom line is that the great majority of the time there'd be zero contact between the CRNA and any of the anesthesiologists. When there was "collaboration" or help needed, the anesthesiologist was in charge and it was essentially 1:1 ACT model for that case.



I see your points, but honestly the "collaboration" was mostly an anesthesiologist telling the CRNAs "you're going to go do these cases today, call if you have questions or need something" and then rarely getting called.

When called, it morphed into something akin to a short-lived 1:1 ACT practice for the duration of a case.


In my military practice, it's much the same, just with better liability insurance, and an explicit requirement for them to discuss all ASA 3 & 4 patients with one of us.


To be clear, I favor a model where anesthesiologist direction of CRNAs happens for every case. But that ship has sailed. For selfish non-patient-centric reasons, I'd rather work in one of these "collaborative" models than run around in a 4:1 ACT. Done both; the "collaborative" workplace is worlds easier.

I’m with you on the “collaborative” model thing and I do think our liability is much lower (and job satisfaction higher) in these models. We’ve all seen situations where consultants are called late to the game after a patient has been mismanaged. However, it’s not hard for me to imagine that the anesthesiologist responsible for “triaging” a case to a CRNA instead of an anesthesiologist will at the very minimum gets deposed in the case of CRNA mismanagement. There are plenty of times where the ASA 2 on paper is actually an ASA 3 upon further questioning. No matter how much hospital administrators and midlevels themselves want to blur the lines, lawyers and patients will always assume the physician is ultimately the one in charge and therefore responsible for any malpractice...even if it’s just a glance at a chart and triaging to an appropriate “provider.”

I am someone who believes there would be no measurable difference between independent CRNA provided care, the ACT model, and MD only care. To be clear, I think there is a difference, but not in the kind of numbers that administrators and businessmen care about. However, there will always be a measurable difference in who assumes liability in cases of mismanagement.

 

[deleted126335]

I’m with you on the “collaborative” model thing and I do think our liability is much lower (and job satisfaction higher) in these models. We’ve all seen situations where consultants are called late to the game after a patient has been mismanaged. However, it’s not hard for me to imagine that the anesthesiologist responsible for “triaging” a case to a CRNA instead of an anesthesiologist will at the very minimum gets deposed in the case of CRNA mismanagement. There are plenty of times where the ASA 2 on paper is actually an ASA 3 upon further questioning. No matter how much hospital administrators and midlevels themselves want to blur the lines, lawyers and patients will always assume the physician is ultimately the one in charge and therefore responsible for any malpractice...even if it’s just a glance at a chart and triaging to an appropriate “provider.”

I am someone who believes there would be no measurable difference between independent CRNA provided care, the ACT model, and MD only care. To be clear, I think there is a difference, but not in the kind of numbers that administrators and businessmen care about. However, there will always be a measurable difference in who assumes liability in cases of mismanagement.

I guarantee you that the contracts and policies will be crafted in such a way that they will attempt to get you on the hook for their decisions. Their goal will be to make you the fire department for misadventure and a lightning rod for liability. Not saying that this is not avoidable with good legal counsel, but the administration, surgeons, and CRNAS will want you to play these parts.

 

[GravelRider]

I guarantee you that the contracts and policies will be crafted in such a way that they will attempt to get you on the hook for their decisions. Their goal will be to make you the fire department for misadventure and a lightning rod for liability. Not saying that this is not avoidable with good legal counsel, but the administration, surgeons, and CRNAS will want you to play these parts.

I don’t disagree that they will try to hook you for some liability...bad triage and it’s difficult to see the sequence of bad management events in the chart after the fact given the speed with which things occur in anesthesia. The CRNA can start struggling with an airway, document an anesthesiologist “consultation” and by the time you get there, anoxic brain injury has set in. It’s difficult to tease that out in a chart and if it was a previously healthy mother of 2, you can guarantee you are getting sued. However, I still think the liability is less by some degree when compared to the 4:1 coverage where you are on roller skates all day...even if simply by less patient care exposure.

 

[deleted162650]

Just let a CRNA write the schedule and triage the rooms. Remove yourself entirely. I mean, they are supposed to be our equals right??

 

[Arch Guillotti]

I actually saw this first hand in my practice. Hospital was sick of dealing with the constant whining and pay increase demands made by CRNAs so much so that they stopped talking to them. Now they are employed by us.

How did it affect your income?

 

[jwk]

"Collaborative care" is a cop-out. So many on this board complain about 1:4 - and with "collaborative care" your ratios are essentially unlimited. You complain about CRNAs doing crazy ****, but you want to increase your staffing ratios where you legally have no need to be involved with the patient?

True medically directed ACT practices work, and work well. But the anesthesiologists have to be committed to the process. In nearly 40 years as an AA, I've never done a case without the anesthesiologist, and that includes a smaller-city practice that only had about 8 docs for two hospitals, and we still managed to cover everything and be within the letter of the law. I've said it a million times - if you cede your practice to the CRNAs on nights and weekends, you are part of the problem.

 

[LebronManning]

Btw, only fools would think that one needs a cardiologist with 7 years of GME to put in a stent or map an arrhythmia.

I think it's a bit disrespectful to make this statement if you've never performed an angioplasty/stenting on a patient with a widowmaker who coded on the way up to the cath lab.

 

[Psai]

I think it's a bit disrespectful to make this statement if you've never performed an angioplasty/stenting on a patient with a widowmaker who coded on the way up to the cath lab.

Cool story bro

 

[deleted59964]

I'd want to let them struggle, but that wouldn't be in the patient's best interest

It’s not in THAT patient’s best interest, but i think it WOULD be in the best interests of MANY future patients.

 

[Status Sciaticus]

It’s not in THAT patient’s best interest, but i think it WOULD be in the best interests of MANY future patients.

Problem is, you can't compare a tangible patient's best interest against hypothetical future patients.

 

[MoMoGesiologist]

I've said it a million times - if you cede your practice to the CRNAs on nights and weekends, you are part of the problem.

I care about the issues, but enough to work nights and weekends? I dunno about that!

 

[GravelRider]

"Collaborative care" is a cop-out. So many on this board complain about 1:4 - and with "collaborative care" your ratios are essentially unlimited. You complain about CRNAs doing crazy ****, but you want to increase your staffing ratios where you legally have no need to be involved with the patient?

True medically directed ACT practices work, and work well. But the anesthesiologists have to be committed to the process. In nearly 40 years as an AA, I've never done a case without the anesthesiologist, and that includes a smaller-city practice that only had about 8 docs for two hospitals, and we still managed to cover everything and be within the letter of the law. I've said it a million times - if you cede your practice to the CRNAs on nights and weekends, you are part of the problem.

If the AANA starting tweeting that they want independent practice so they can work all the nights and weekends, I would join Twitter and retweet that like a million times.

If that is all that differentiates me from a CRNA...willingness to do nights and weekends...then I don’t want it.

 

[pgg]

"Collaborative care" is a cop-out. So many on this board complain about 1:4 - and with "collaborative care" your ratios are essentially unlimited. You complain about CRNAs doing crazy ****, but you want to increase your staffing ratios where you legally have no need to be involved with the patient?

True medically directed ACT practices work, and work well. But the anesthesiologists have to be committed to the process. In nearly 40 years as an AA, I've never done a case without the anesthesiologist, and that includes a smaller-city practice that only had about 8 docs for two hospitals, and we still managed to cover everything and be within the letter of the law. I've said it a million times - if you cede your practice to the CRNAs on nights and weekends, you are part of the problem.

Huh

I'm not sure how I could've been clearer:

To be clear, I favor a model where anesthesiologist direction of CRNAs happens for every case. But that ship has sailed. For selfish non-patient-centric reasons, I'd rather work in one of these "collaborative" models than run around in a 4:1 ACT. Done both; the "collaborative" workplace is worlds easier.

Independent practice has been ceded.

This is the world we live in.

Given the choice of doing my own cases and not being responsible for the CRNAs' cases, vs providing lip-service chart-signing malpractice coverage to 4 or 6 or 8 at a time, it's an easy choice.

You're very fond of telling us how great things are in your group ... at least from your perspective as the supervised AA.

It's a rare anesthesiologist who gets any satisfaction (beyond a paycheck and a job) from supervision.

I've decided to opt out. I'll do my own cases and I'm willing to earn less to do so.

 

[chocomorsel]

@jwk, I only agree with you about the nights and weekends part. If you gonna do it in the daylight hours do it at night as well and the weekends that everyone hates.

However, supervision sucks! Running around like chickens with their heads cut off amongst three or four rooms sucks and is difficult/stressful on the brain and the body.

Most here would agree were it not for the typically more money earned the ACT model. Most do it for the money and or family ties that keep them in certain ACT heavy areas.

 

[deleted171991]

I think it's a bit disrespectful to make this statement if you've never performed an angioplasty/stenting on a patient with a widowmaker who coded on the way up to the cath lab.

Respectfully, it's 90+% monkey skills. I don't think there is much that one learns in the 6 years of GME before the interventional year that one needs to put in stents. It's not brain surgery, no offense. Like it or not. So the future may be 2-3 EP/IC labs with techs/APRNs/PAs and a subspecialized cardiologist supervising them.

I know I am pushing the envelope, but this is how big healthcare corporations think. "Top of the license". It won't happen overnight, but I wouldn't bet against it in 20-30 years.

 

[skypilot]

Huh

I'm not sure how I could've been clearer:



Independent practice has been ceded.

This is the world we live in.

Given the choice of doing my own cases and not being responsible for the CRNAs' cases, vs providing lip-service chart-signing malpractice coverage to 4 or 6 or 8 at a time, it's an easy choice.

You're very fond of telling us how great things are in your group ... at least from your perspective as the supervised AA.

It's a rare anesthesiologist who gets any satisfaction (beyond a paycheck and a job) from supervision.

I've decided to opt out. I'll do my own cases and I'm willing to earn less to do so.

This is awesome. Where are all the CRNAs who need supervision going to go if we all opt out? Maybe the CEOs, AMC recruiters, hospitals and surgeons can absorb all that liability.

 

[GA8314]

Supervising is less professionally rewarding than sitting my own cases.

I do think that I'd rather "cede" territory than be a supervision jockey at >4:1 ratios because at that point you aren't doing sh.t and the battle would be lost anyway. I just don't see how that could be fun at all. I'd rather take a pay cut and my lifestyle will reflect this in the meantime.

That said, in a mostly ACT model, I still make a difference day to day. But, if that were ever to change, I'd sit my own and the pay would be what it is.

 

[dannyboy1]

This is awesome. Where are all the CRNAs who need supervision going to go if we all opt out? Maybe the CEOs, AMC recruiters, hospitals and surgeons can absorb all that liability.

No danger of that. Plenty of older docs enjoy supervising (I.e. sitting on your @ss). I have also observed that the longer people are in practice especially if in one group/institution, the less people worry about malpractice and liability.

 

[WholeLottaGame7]

I think it's a bit disrespectful to make this statement if you've never performed an angioplasty/stenting on a patient with a widowmaker who coded on the way up to the cath lab.

What if that were the only type of case you got to do, though, because the cardiology PAs/NPs took all the bread-and-butter diagnostic heart caths and then published weak studies claiming equivalence?

 

[GravelRider]

Respectfully, it's 90+% monkey skills. I don't think there is much that one learns in the 6 years of GME before the interventional year that one needs to put in stents. It's not brain surgery, no offense. Like it or not. So the future may be 2-3 EP/IC labs with techs/APRNs/PAs and a subspecialized cardiologist supervising them.

I know I am pushing the envelope, but this is how big healthcare corporations think. "Top of the license". It won't happen overnight, but I wouldn't bet against it in 20-30 years.

The big healthcare corporations won’t have to push it. Once the cardiologists realize they can supervise 4:1 (and bill 4:1) they will welcome their “cathing techs” with open arms.

 

[chocomorsel]

This is awesome. Where are all the CRNAs who need supervision going to go if we all opt out? Maybe the CEOs, AMC recruiters, hospitals and surgeons can absorb all that liability.

They can be supervised by the Rockstar CRNAs who need no supervision and practice at the top of their license. I can totally see this happening with the cocky and bully CRNAs who think they are equivalents to docs. Lol

 

[chocomorsel]

Respectfully, it's 90+% monkey skills. I don't think there is much that one learns in the 6 years of GME before the interventional year that one needs to put in stents. It's not brain surgery, no offense. Like it or not. So the future may be 2-3 EP/IC labs with techs/APRNs/PAs and a subspecialized cardiologist supervising them.

I know I am pushing the envelope, but this is how big healthcare corporations think. "Top of the license". It won't happen overnight, but I wouldn't bet against it in 20-30 years.

Is this specialty bashing really necessary?

Just because our specialty is screwed doesn’t mean we need to go be disrespectful to other specialties and tell them they aren’t needed.

How do you know what their training really entails? Have you been thru it?

Don’t you love it when surgeons act like know it alls and think they can easily do our jobs since nurses do it as well and it seems so easy? How is that any different than what you are doing here?

 

[deleted171991]

Is this specialty bashing really necessary?

Just because our specialty is screwed doesn’t mean we need to go be disrespectful to other specialties and tell them they aren’t needed.

How do you know what their training really entails? Have you been thru it?

Don’t you love it when surgeons act like know it alls and think they can easily do our jobs since nurses do it as well and it seems so easy? How is that any different than what you are doing here?

I am just playing the devil's advocate here. Everybody is needed, or nobody is needed. Today anesthesiology, tomorrow others. Many other specialties think they are so protected because what they do is so special. Guess what? Nobody is special, at least not in the eyes of the greedy corporate types.

We also like to think that X years of GME will protect us, because patient care comes first. It doesn't. Money comes first.

I want to see physicians uniting and unionizing, regardless of specialty. Midlevels, nurses and hospital systems are winning by divide and conquer tactics. At the same time, they are 100 times more united as interest groups.

I hope you have a good and righteous night.

 

[Status Sciaticus]

What if that were the only type of case you got to do, though, because the cardiology PAs/NPs took all the bread-and-butter diagnostic heart caths and then published weak studies claiming equivalence?

Then you publish strong studies claiming otherwise.

They can be supervised by the Rockstar CRNAs who need no supervision and practice at the top of their license. I can totally see this happening with the cocky and bully CRNAs who think they are equivalents to docs. Lol

And when preventable deaths occur, they will change their tune real quick.

 

[LebronManning]

The big healthcare corporations won’t have to push it. Once the cardiologists realize they can supervise 4:1 (and bill 4:1) they will welcome their “cathing techs” with open arms.

There’s not enough cath volume for that. There was plenty of surgical volume for anesthesiologists to supervise CRNAs.

 

[chocomorsel]

I am just playing the devil's advocate here. Everybody is needed, or nobody is needed. Today anesthesiology, tomorrow others. Many other specialties think they are so protected because what they do is so special. Guess what? Nobody is special, at least not in the eyes of the greedy corporate types.

We also like to think that X years of GME will protect us, because patient care comes first. It doesn't. Money comes first.

I want to see physicians uniting and unionizing, regardless of specialty. Midlevels, nurses and hospital systems are winning by divide and conquer tactics. At the same time, they are 100 times more united as interest groups.

I hope you have a good and righteous night.

Well then, now that you clarified it,
PREACH ON! UNIONIZE!

How do we start? One of the reasons I went to my residency was because of the union.

 

[AdmiralChz]

There’s not enough cath volume for that. There was plenty of surgical volume for anesthesiologists to supervise CRNAs.

Oh, there definitely is at many academic and community centers. The cath lab runs 4 rooms a day and 2 at night Almost continuously at the job I start next month, and it’s community-based.

Here at a tertiary center the volume is nearly limitless.

 

[deleted162650]

One of the reasons I went to my residency was because of the union.

And how’d that work out for you?

 

[LebronManning]

Oh, there definitely is at many academic and community centers. The cath lab runs 4 rooms a day and 2 at night Almost continuously at the job I start next month, and it’s community-based.

Here at a tertiary center the volume is nearly limitless.

I read somewhere that the average interventionalist only does 50-75 interventions per year and there’s a lot less interventional cardiologists than surgeons. Diagnostic Caths aren’t included in that number and maybe it’s double or triple that number

 

[AdmiralChz]

I read somewhere that the average interventionalist only does 50-75 interventions per year and there’s a lot less interventional cardiologists than surgeons. Diagnostic Caths aren’t included in that number and maybe it’s double or triple that number

I have no idea what the average is, but your sorta random number might speak to a relative oversupply of interventionalists (ask a cardiology fellow how the job market is these days....).

I am mostly talking about diagnostic caths, the easiest and most straightforward cases which FFP is referring to which are ripe for the picking.

 

[chocomorsel]

And how’d that work out for you?

Great. When the evil bitch PD tried everything in her power to ruin me, the union helped me fight and win.

My residency would have been fine had the PDs not changed midway thru and we ended up with a rabid bitch trying to make a name for herself in academics.

 

[VA Hopeful Dr]

I have no idea what the average is, but your sorta random number might speak to a relative oversupply of interventionalists (ask a cardiology fellow how the job market is these days....).

I am mostly talking about diagnostic caths, the easiest and most straightforward cases which FFP is referring to which are ripe for the picking.

Or the ever increasing body of evidence that says stents outside of STEMIs aren't of much value...

 

[deleted171991]

There’s not enough cath volume for that. There was plenty of surgical volume for anesthesiologists to supervise CRNAs.

That's an excellent point.

I should have given GI and routine colonoscopies as an example that is ripe for takeover. There are already academic centers where one GI attending supervises multiple fellows doing procedures at the same time.

 

[mmag]

"Specializing in colonoscopies has made nurse practitioner Monica VanDongen especially skilled."

Inside Tract - Who's traversing the tract?

That's an excellent point.

I should have given GI and routine colonoscopies as an example that is ripe for takeover. There are already academic centers where one GI attending supervises multiple fellows doing procedures at the same time.

 

[mmag]

Ms Yasin is a nurse—an advanced practice nurse, and now, a skilled nurse angiographer. Her study aimed to show that nurses can be taught to perform coronary angiography with the same safety, efficiency, and quality as doctors in training.

Dr Piers Clifford, one of her physician mentors, told me that "we did not train Ms Yasin to do angiography because we needed another person to do procedures; we trained her to keep her in our department." Clifford said she had been a cath-lab nurse for 5 years and had advanced to the highest level in clinical nursing. Going further in nursing meant moving into administration, away from the bedside.

Yasin wanted to stay in clinical care, and Clifford did not want to lose a talented and motivated caregiver. "Frankly, if someone has manual dexterity, compassion, training, and common sense, they don't need to be a doctor to perform an angiogram; once you have seen 5000 angiograms [as she had], you know which views to take, which catheters to switch to if intubation is difficult," Clifford said.

Medscape: Medscape Access

I have no idea what the average is, but your sorta random number might speak to a relative oversupply of interventionalists (ask a cardiology fellow how the job market is these days....).

I am mostly talking about diagnostic caths, the easiest and most straightforward cases which FFP is referring to which are ripe for the picking.

 

[GravelRider]

Ms Yasin is a nurse—an advanced practice nurse, and now, a skilled nurse angiographer. Her study aimed to show that nurses can be taught to perform coronary angiography with the same safety, efficiency, and quality as doctors in training.

Dr Piers Clifford, one of her physician mentors, told me that "we did not train Ms Yasin to do angiography because we needed another person to do procedures; we trained her to keep her in our department." Clifford said she had been a cath-lab nurse for 5 years and had advanced to the highest level in clinical nursing. Going further in nursing meant moving into administration, away from the bedside.

Yasin wanted to stay in clinical care, and Clifford did not want to lose a talented and motivated caregiver. "Frankly, if someone has manual dexterity, compassion, training, and common sense, they don't need to be a doctor to perform an angiogram; once you have seen 5000 angiograms [as she had], you know which views to take, which catheters to switch to if intubation is difficult," Clifford said.

Medscape: Medscape Access

Let’s be honest, Dr. Clifford is probably banging Ms. Yasin.

 

[Psai]

Ms Yasin is a nurse—an advanced practice nurse, and now, a skilled nurse angiographer. Her study aimed to show that nurses can be taught to perform coronary angiography with the same safety, efficiency, and quality as doctors in training.

Dr Piers Clifford, one of her physician mentors, told me that "we did not train Ms Yasin to do angiography because we needed another person to do procedures; we trained her to keep her in our department." Clifford said she had been a cath-lab nurse for 5 years and had advanced to the highest level in clinical nursing. Going further in nursing meant moving into administration, away from the bedside.

Yasin wanted to stay in clinical care, and Clifford did not want to lose a talented and motivated caregiver. "Frankly, if someone has manual dexterity, compassion, training, and common sense, they don't need to be a doctor to perform an angiogram; once you have seen 5000 angiograms [as she had], you know which views to take, which catheters to switch to if intubation is difficult," Clifford said.

Medscape: Medscape Access

We have too many subpar "angiographers" as it is without creating another provider with even crappier training. Our patients deserve better than people doing procedures just to do procedures.