The future and survival of anesthesiology depends on this as the opening session at ASA really ground in this morning-and I agree. Anyone out there actively implementing the PSH?
Does this stuff mean anesthesiologist of the future are going to be doing all the paperwork, endless rounding, and social work that internists do today? Basically anesthesiologists becoming the PCP for every surgical patient for 30 days? If so, this is absolute garbage. Nobody going into anesthesiology has the desire to be a PCP, baby sit surgical patients, and deal with all of the nightmare social issues that come with it. I would rather work for 80K in the OR than become an internist. One of the main reasons that I'm staying away from surgery is that I HATE all the clinic and rounding that they have to do. If I'm going to be be forced into doing clinic for surgeons, I'd rather do pain clinic or sleep medicine clinic for my own patients.
PSH strives to achieve the triple aim of better health, better health care, and reduced expenditures through continuous improvement for all patients undergoing surgical procedures. The PSH is a patient-centered, physician-led, multidisciplinary, and team-based system of coordinated care. It guides the patient through the entire surgical experience from decision for the need for surgery until 30 days post discharge from a medical facility. The goal is to create a better patient experience and make surgical care safer; thus, promoting a better medical outcome at a lower cost.
My understanding is that the PSH is the system that coordinates the care for a surgical patient from the time a surgeon determines a surgery is indicated through ~30 days post op.Can someone explain what is meant by Periop Surgical Home? Whenever I look it up I find some verbose answers that really don't explain what it is.
And what in the world does this mean? I mean, it sounds fancy with words like "optimizing" and "overseeing" but what is the practical application of this? Sounds to me like you'll just be another internist for surgical patients writing all the long H&Ps, dealing with complications, finding placement for patients, rounding on them, seeing them in clinic post-op, etc... Yeah, forget about it. I will subspecialize and do three years of fellowship training if I have to before getting involved in this garbage. You can't pay me enough to be the surgeon's social work slave.No not from my understanding, they envision some anesthesiologists optimizing, overseeing and coordinating the care of the surgical patient throughout the peri operative period.
This means that you are on the hook for anything that happens to that surgical patient within that 30 days. It's blame shifting. You know, when that patient goes home and they start smoking again, their dog licks their surgical site, they don't take their medication as directed, and the wind up bouncing back. That is going to be on you now.My understanding is that the PSH is the system that coordinates the care for a surgical patient from the time a surgeon determines a surgery is indicated through ~30 days post op.
UC Irvine has a very well developed system and it's impressive what they have been able to do in a few short years. U Alabama does too and many PP groups are also developing them (Christina care in Delaware - can't remember the group name). I still believe that this can work for any practice if the right people are interested. I also believe change is coming whether we want to be a part of it or not is up to us.
We do not become the surgeons internists or slaves - I'm not interested in writing endless H&Ps either - I hated medicine clinic and wards. Usually if there is a problem preop (which diabetes is one of the huge issues in our institution), we plan with the internist to get it under better control. I do not write prescriptions and I am not the main person following up with the patient, that is their PCPs job (and they know the patient best anyway so I don't pretend to fill that role). I think of it as I'm a final gate keeper to the patient going for surgery and it's my job to make sure they are optimized (health management, weight, blood pressure, HR control if needed, proper diabetes management, etc). It's not uncommon that I will see a patient with a hba1c >10 come through our clinic. Maybe because we are the final point person for ordering labs and the surgeons are unaware of it until then, not sure how other organizations order labs (if the surgeons are better at catching this).
At my institution we have initiated parts of the surgical home and it has worked well - we still have a lot of work to do but we have various groups working with various surgical teams. We've taken control of most of the pain management issues and are working very hard in our preop clinic to really get patients optimized for surgery. We have completely changed many of pre-op protocols and are aiming to get the patient from the door to OR in less time (by moving the way we do preop influx of patients).
How are anesthesiologists better at doing any of those things? I would argue we are worse at all of them, and further, are prone to ignore when the patient is off the "protocol" to keep the surgeons happy and the OR full and making money. Especially outside of the world of academia.Many have implemented different ways to help manage the things that anesthesia providers are best at managing and making sure patients remain on 'protocols' (making sure they get out of bed, making sure they get their prescriptions, making sure they understand instructions).
I said it already and I will say it again: in my view, the PSH tries to change the anesthesiologist into a surgical hospitalist/NP coordinator, so that the surgeon can stay more in the OR and make more money for the hospitals, fewer surgeries get cancelled, fewer patients get readmitted etc. I wouldn't be surprised if it came with call requirements, so that the dear valuable patient-bringing surgeons can rest more than the worthless expensive overqualified anesthesiologists.Seems like the surgical home is a plan to eliminate stand alone medicine doctors. I can see the hospitals supporting that. I don't know how the patient benefits or what additional service we anesthesiologist we provide them.
You don't turn him over to some hospitalist, you take him over yourself to coordinate preop and post op care. The surgeon just becomes a cog in the wheel cutting away and moving on to the next. Like IR is now. IR has no patients. They eval patients when consulted for procedures then do them and move along to the next one.I noticed I'm not the only one who does not have clear what a surgical home is. From the get go seems like it is going to be a flop if people don't when know what it is.
I don't get the difference between having a preop clinic and beeing a surgical home. Let's say instead of getting a "clearance" by his cardiologist, now we channel the patient through in-house specialist and sign off on it as a last step in the clinic. Seems like our role is actually diminished. We are basically handing off the preop process to in-house internists and just saying hello after all the work has been done.
I don't know how this is an improvement from current practice. The hospital internists benefit, not us.
I don't understand the post op 30 days. What are we supposed to do? Make sure they are back on their pills and insulin. Do we really need 30 days for that?
Seems like the surgical home is a plan to eliminate stand alone medicine doctors. I can see the hospitals supporting that. I don't know how the patient benefits or what additional service we anesthesiologist we provide them.
Once the hospital gets control of the patient stream, they will ask for the lump sum payment to get control of the physician's revenue stream.
Exactly. Instead of the anesthesiologist being the consultant, it's almost like the surgeon is.You don't turn him over to some hospitalist, you take him over yourself to coordinate preop and post op care. The surgeon just becomes a cog in the wheel cutting away and moving on to the next. Like IR is now. IR has no patients. They eval patients when consulted for procedures then do them and move along to the next one.
Orthopedic surgeons have been doing this for some time now. The Internal Medicine doc takes care of all of the "medical" problems. The surgeon just does the operation.Exactly. Instead of the anesthesiologist being the consultant, it's almost like the surgeon is.
Not sure how this is going to play out. Let's assume that you take over the complete preop and post op process. Basically you notice he has SOB on exertion and his BP & glucose is high, and send him to an internist to have that worked up. I'm not sure what was your grand role in the whole thing if you had someone else fix the issues, but let's go on. You approve him for surgery and let's assume everything goes well. The patient spends a few days in-house in which you round like an internists making sure his labs are ok, his x rays were done, coordinate PT and social work..... Patient goes home and you keep calling him and listening to a long litany of complaints every couple of days for a month...You don't turn him over to some hospitalist, you take him over yourself to coordinate preop and post op care. The surgeon just becomes a cog in the wheel cutting away and moving on to the next. Like IR is now. IR has no patients. They eval patients when consulted for procedures then do them and move along to the next one.
Every day a dedicated anesthesiologist visits all inpatients who underwent surgery and/or anesthesia the day prior and continues to follow those patients with unresolved medical issues as needed. We often interface with the patient's ongoing care team that includes surgeons, intensivists, and primary internists/subspecialists. Patients and their families have ample time to ask questions and have any unmet needs addressed. We pay special attention to anesthetic sequelae, the inpatient management of chronic medical conditions, and pain control in our patients.
Employed? Does that mean anesthesiologists can at least form a union?I know many folks hate rounding and enjoy the lack of it in the OR, but those of us doing CCM don't mind rounding some of us might even enjoy it. Not everyone needs to round, reportedly the majority of folks will continue to practice OR anesthesia the way they do now but with perhaps more supervision (4+ rooms), and likely in an employed position by a hospital or AMC.
I still am asking - what is your alternative?????
Honestly, do you have any experience with what you're talking about? I have seen ZERO moves in our market for reimbursing for the anesthetic. CMS is always good for tinkering with rules and what not, but I think you are being very presumptuous. VERY presumptuous.No not from my understanding, they envision some anesthesiologists optimizing, overseeing and coordinating the care of the surgical patient throughout the peri operative period. The majority of anesthesiologists will continue to work in the OR as they do today. Yes, it's a new idea and dramatic shift from current practices but I haven't heard of any other reasonable solutions as to how anesthesiologists are to remain relevant with the advent of ACO's and bundled payments etc. Whether we like it or not, the way we practice medicine and are reimbursed in the future is changing. That part is out of our control, we can either evolve and adapt to the new environment or let somebody else fill the niche while we allow the specialty to become marginalized.
Honestly, do you have any experience with what you're talking about? I have seen ZERO moves in our market for reimbursing for the anesthetic. CMS is always good for tinkering with rules and what not, but I think you are being very presumptuous. VERY presumptuous.
Exactly. This is not the answer to the future. Anesthesiologists don't have to "change" the profession to cater to some nurse. It's this stupid mentality of bending over for these stupid militant nurses that got us in the predicament in the first place. The only thing we need to change about the specialty is the push-over cowardly mentality many physicians within the field have. MDs must fight for their position in the OR tooth and nail until the very end. Educate the public, use propaganda if we have to like the nurses do, make sure everyone in the country is aware that hospitals are willing to risk patient's lives to save a few pennies. In some polls, 90% of the patients state that they want a physician supervision all aspects of anesthesia care and 70% believe ONLY physicians should be part of this care. The public must be educated on the situation through whichever means are necessary. That will put pressure on surgeons and administrators to do what is right for patients.
Come on guys, we are going to bend over and take it from nurses with less than 1/10 our education? This is utter BS.
Will lawyers be okay with suing nurses when things go wrong? Will nurses be willing to be legally held accountable? What about surgeons?
Despite all of the objections, I'm a proponent of the perioperative surgical home.
Given the relentless political agenda of the AANA, the Institute of Medicine report on scope of practice, mounting cost containment pressures, and the rising tide of "opt out" states, now (more than ever) anesthesiologists need to demonstrate their value in health care settings. Anesthesiologists need to have a pervasive presence in health care settings, playing a key role in every step of the continuum of perioperative care.
Preooperative care needs to extend well beyond the day of surgery. I think it's crazy that anesthesiologists are expected to meet patients for the first time on the day of surgery! How can you establish a relationship with the patient? How can you gain the patient's trust quickly? Emergency surgeries are an obvious exception, but for elective surgeries? Anesthesiologists, like surgeons, should have some ownership of patients, and the only way to do that is to be involved in the clinic setting.
I can imagine a situation, in which an anesthesiologist is "embedded" (for lack of a better term) in one or more surgical clinics. Any patients who are deemed surgical candidates on a given day would be seen by the anesthesiologist the same day. Scheduling would then be created in a way that the same anesthesiologist would be supervising the patient's anesthetic. That's how anesthesiologists can get some degree of ownership in the process. In addition, this is how very close bonds can be formed between anesthesiologists and surgeons.
Preoperative testing would be controlled exclusively by anesthesiologists. No more unnecessary testing, which only serve to increase the overall cost of care. Preoperative optimization would be controlled by anesthesiologists. Anything that falls outside the anesthesiologist's comfort zone would warrant consultation. The average anesthesiologist knows a ton of medicine. It's not unreasonable to expect an anesthesiologist to handle the lion's share of preoperative optimization.
Intraoperative logistics would be under the purview of anesthesiologists, involving the appropriate supervision (or lack thereof at the anesthesiologist's discretion). High acuity patients may warrant 1:1 supervision whereas a bunch of low acuity patients in low risk surgeries may only require 1 anesthesiologist supervising 10 CRNAs. What's more, many cases may not require any supervision, but that decision should be up to the anesthesiologists at a particular facility.
Immediate postoperative care (the first 24-48 hrs maybe?) would also be controlled by anesthesiologists.
Then things could be transitioned to hospitalists. Anesthesiologists get a huge dose of critical care in training. Why on earth would you NOT want an anesthesiologist handling the immediate postoperative setting?
I don't understand why people are opposed to this idea. Anything that gets anesthesiologists more inextricably involved in the process of perioperative care is a good thing, because that's what makes people in organizations irreplaceable. With all of the AMCs on the horizon and CRNAs desperately trying to gain more traction in the intraoperative setting, this is a godsend.
Just my $0.02.
Nice. According to you, our best hope is the ambulance chaser. I guess that you are against tort reform?Will lawyers be okay with suing nurses when things go wrong? Will nurses be willing to be legally held accountable? What about surgeons?
I feel like anesthesiologists will have a place in the OR as long as lawyers want money.
I am not against tort reform. I'm an MS3 planning on applying to anesthesiology. I just want the field to be in a good position by the time I'm finished training. I guess I was trying to justify, perhaps incorrectly, why anesthesiology will continue to have it relatively good.Nice. According to you, our best hope is the ambulance chaser. I guess that you are against tort reform?
There will always be a place for anesthesiologists in ORs.
The questions are:
How many will be needed? Answer: Most likely Fewer.
What type of place? Answer: Quite a bit different than most of us are used to.
Anesthesiologists, as physicians, will stand head and shoulders above ANY CRNA when it comes to preoperative assessment, especially of the undifferentiated patient. Physicians are the gold standard when it comes to the diagnosis and formulation of treatment plans for disease. If the goal is to perform an excellent history to generate a preliminary differential diagnosis, perform a focused but effective physical examination to test the hypotheses on the differential, and to RATIONALLY order tests to clinch the diagnosis, a physician is hands-down the best option. We have (by far) the most training in this area. Also, when it comes to formulating treatment plans, again, physicians are the gold standard. We have FAR more training in the complex process of weighing risks and benefits to create a rational, evidence-based, and (hopefully) effective treatment plan. We are tested to death on this process--every single day on the wards as a medical student, intern, and resident emphasizes this skill set. "Optimizing" medical conditions for surgery is just another iteration of formulating a treatment plan.While I don't agree with every part of this post, the one idea that I love is patient ownership. If anesthesiologists could split patient ownership with the surgeon it would do an amazing thing for the specialty. It would be great if patients knew their anesthesiologist and could pick him/her ahead of time instead of being assigned one the day of surgery. This may help patients become more familiar with the role and value of an anesthesiology and may make it harder for doctors to be replaced by nurses.
On the other hand, what's going to stop encroachment on this turf by CRNAs? What if an AMC decides that they will now provide "low cost" perioperative services by supplying all of those preop clinics with CRNAs. It seems like midlevels will have no problem stepping into these roles as currently, a lot of midlevels already do these things under the supervision of surgeons.
Because anesthesiologists will be paid **** for this. It will be part of the usual OR anesthesia fees. That's why it didn't happen in the past, and that's why they'll have a difficult time selling it now.Sounds a lot like a modified European type of practice of an anesthesiology, and less like a new idea. In theory it makes sense but I wonder about the difficulty in implementation. I personally see this all the time patients needing "clearance" from specialist xyz for no real defined reason. But who understands the stress of surgery and the physiological changes better than an anesthesiologist? Why would you not want them captaining you through this surgical period?
This isn't capitalism. This is people using lobbying and legislative muscle (regulation and tax protection, especially in the not-for-profits) to protect themselves. They don't want pure capitalism.We all love capitalism until it's used against us.