Association of Anesthesiologist Staffing Ratio With Surgical Patient Morbidity and Mortality

[anbuitachi]

Our healthcare system over treats and over utilizes surgical interventions, the emphasis on prevention and a non processed diet is not existent. The medical industrial complex is big and that’s why We have a larger “need “ than Canada

but we have 50% more anesthesiologists per capita. i actually dont know how many more procedures we do per capita vs canada, but id be surprised if we do THAT many more procedures to justify 50% more anesthesiologists and MANY MANY crnas

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[Hoya11]

Found this on Google about Canada

The Canadian Medical Association published the 2018 Anesthesiology Profile showing a total of 3321 Physician Anesthesiologists in Canada or 9 per 100 000 Canadians. In contrast the United States has 47 000 Physician Anesthesiologists which is 14.4 per 100 000.

For those of you who day WE NEED CRNAS . How does Canada do it? I don't hear daily about how bad Canada's healthcare is ... I think it'll be fine? We have 50% more anesthesiologists per capita than Canada yet we NEED CRNAS?

in the US as a whole yes, those numbers are the average.

but how do you provide service to the most densely populated areas?

whats canadas most densely populated city? not comparable to the northeast cities or LA

what is the anesthesiologist ratio in the NYC area per 100,000 population?

i would love to go MD only, but I challenge all those who work in that model to post WHERE they practice, im guessing its not a major metro area

NYC area is literally ALL ACT. I dont think I could find an MD only job if I was determined to find one

 

[Hoya11]

Our healthcare system over treats and over utilizes surgical interventions, the emphasis on prevention and a non processed diet is not existent. The medical industrial complex is big and that’s why We have a larger “need “ than Canada

agree 100% our uniquely private system creates inefficiency and waste of our services due to spreading the same cases around different health systems and doing lots of BS cases

 

[coffeebythelake]

Found this on Google about Canada

The Canadian Medical Association published the 2018 Anesthesiology Profile showing a total of 3321 Physician Anesthesiologists in Canada or 9 per 100 000 Canadians. In contrast the United States has 47 000 Physician Anesthesiologists which is 14.4 per 100 000.

For those of you who day WE NEED CRNAS . How does Canada do it? I don't hear daily about how bad Canada's healthcare is ... I think it'll be fine? We have 50% more anesthesiologists per capita than Canada yet we NEED CRNAS?

Canada's healthcare system prioritizes primary care. Not many surgeries are performed, and there js a long wait for elective surgeries. That's why.

 

[nimbus]

in the US as a whole yes, those numbers are the average.

but how do you provide service to the most densely populated areas?

whats canadas most densely populated city? not comparable to the northeast cities or LA

what is the anesthesiologist ratio in the NYC area per 100,000 population?

i would love to go MD only, but I challenge all those who work in that model to post WHERE they practice, im guessing its not a major metro area

NYC area is literally ALL ACT. I dont think I could find an MD only job if I was determined to find one

With the exception of Kaiser and academics, LA is largely MD only as is Orange County, the Bay Area and San Diego. They’re all dense metro centers, denser than most of the country. If it can be done in California with our crappy contracts, crappy payor mix, and VHCOL, it’s hard to imagine that it can’t be done everywhere else. Outside California, I know of MD only practices in Dallas, Houston, Phoenix, Denver, Chicago, Seattle, Las Vegas, etc, etc. I thought NYC even had a few MD only practices but my information is admittedly not up to date.

MD only is a trade off with generally lower incomes (there’s a poster here who says he makes $900k-$1mil+ working 40hrs/week doing medical direction. That’s not likely in MD only.) and more unpredictable schedules (no option to increase ratios and send anesthesiologists home in the evening) but lots of people willingly do it.

 

[nimbus]

Canada's healthcare system prioritizes primary care. Not many surgeries are performed, and there js a long wait for elective surgeries. That's why.

This is an interesting link. No data for canada but a few South American countries and many European countries do significantly more surgeries per capita than we do. I think Brazil has a C-section rate close to 80%. Colombia, Denmark, Belgium, Luxembourg, and Switzerland are at the top of the list. We’re in the middle.

Number of surgical procedures (per 100,000 population) | Data

Number of surgical procedures (per 100,000 population) from The World Bank: Data

data.worldbank.org

 

[Hoya11]

With the exception of Kaiser and academics, LA is largely MD only as is Orange County, the Bay Area and San Diego. They’re all dense metro centers, denser than most of the country. If it can be done in California with our crappy contracts, crappy payor mix, and VHCOL, it’s hard to imagine that it can’t be done everywhere else. Outside California, I know of MD only practices in Dallas, Houston, Phoenix, Denver, Chicago, Seattle, Las Vegas, etc, etc. I thought NYC even had a few MD only practices but my information is admittedly not up to date.

MD only is a trade off with generally lower incomes (there’s a poster here who says he makes $900k-$1mil+ working 40hrs/week doing medical direction. That’s not likely in MD only.) and more unpredictable schedules (no option to increase ratios and send anesthesiologists home in the evening) but lots of people willingly do it.

weve got thousands of full time employed CRNAs around here, thousands of employed full time anesthesiologists, everyone working at a crazy pace, still lots of job openings, i just dont know where we would get the extra docs if we got rid of the crnas... i truly dont know how those other places do it.. hard for me to understand. in fairness i dont think the cities you mentioned, except for maybe LA and Chicago, are apples to apples with NYC.

 

[aneftp]

The MD model is the best model but simply not practical in many settings. Especially during busy 7-3pm times. Some one needs to be free for extra hand if pacu problems. Doing peds ent, you are asking for trouble if no free MD available.

It becomes a contentious issue with hospital administrators (who already give no subsidy in many big cities/suburbs). How’s the free MD from 7-3pm getting paid. When the private group either
Bills blended unit or pure fee for service or “on the clock/room time”.

 

[teacher2md]

I currently work in a PP group ACT model that bends the rules of medical direction. It’s the culture here that the CRNAs emerge without giving you a heads-up, and not infrequently they’ll induce a patient by themselves when the anesthesiologist is tied up giving a morning or lunch break.

We also utilize SRNAs as solo providers to substitute for CRNAs in a 1:2 ratio. I know this doesn’t violate TEFRA but it’s not right.

I’m leaving for a much better group.

 

[OptionOffense]

The MD model is the best model but simply not practical in many settings. Especially during busy 7-3pm times. Some one needs to be free for extra hand if pacu problems. Doing peds ent, you are asking for trouble if no free MD available.

It becomes a contentious issue with hospital administrators (who already give no subsidy in many big cities/suburbs). How’s the free MD from 7-3pm getting paid. When the private group either
Bills blended unit or pure fee for service or “on the clock/room time”.

The only problem with solo md for administrators is the lack of flexibility of the model. You dont have anyone free. If anyone is free who is going to pay them. You WANT to be doing cases for the Rvus. So when an add on case comes along, when problems arise in the pacu, when intubations happen on the floor and other such things. You need a free body to handle them. Moreover, if one MD falls ill .. you close a room completely. That only has to happen once or twice for them to bring in CRNAs. WHen efficiency was not paramout 10-20 years ago it was ok, now I feel it is more catastrophic to cancel an entire days cases for a no show.
Going forward, I think the future will be expanding the roles of CAAs as midlevels and even PAs turned CAAs. There just simply is too much demand for RNs solely to become anesthetists and it just worsens the staffing shortages of the ICU RN pool. We need another avenue of staffing.

 

[OptionOffense]

I currently work in a PP group ACT model that bends the rules of medical direction. It’s the culture here that the CRNAs emerge without giving you a heads-up, and not infrequently they’ll induce a patient by themselves when the anesthesiologist is tied up giving a morning or lunch break.

We also utilize SRNAs as solo providers to substitute for CRNAs in a 1:2 ratio. I know this doesn’t violate TEFRA but it’s not right.

I’m leaving for a much better group.

This would NEVER be ok with me

 

[chocomorsel]

They know they are providing worse care. Unfortunately that is the system we've built and/or started working in.

Most supervision jobs you sign charts and run to pre-op, post-op, place blocks, and hope nothing happens in the meantime while mediocre nurses "provide anesthesia". Many of us would never tolerate the anesthesia being provided to patients under our care by those CRNAs if it were our family member, and yet we stay quiet. Why? It's the system. Just like nurses should have fixed ratios, so should anesthesiologists. Once complexity of case or ASA status goes up, that ratio should be lowered even further. We all know this and yet are afraid to say it out loud.

Oh please. Plenty of people on here love and tout how great this system is because they make a **** ton of money off the nurses. I am talking about practice owners and partners who want to be 1:4 so that can make 700K+ instead of 500k.
Come on, these people don’t try to bring on more Doctors because that means they would have to split the pie even more. They want to keep as much money as possible.
The first person who responded to this thread is one of those people. And there are plenty more. Nobody’s forcing these people to do 1:4, they want to do this to make the most amount of money. All greed. It’s not just “the system”. They “system” was started by doctors.

 

[chocomorsel]

Have you ever worked in a MD only model?

Hahahahahahahhahaha!
Hahahahhahahahahahhahahahahahhaha!!!!
Hahahhahahahahahahahhahhahahhahahahahhahahahhahahah!!!!

 

[chocomorsel]

yes, why?

And I am sure you will never go back to work for those peanuts.

 

[chocomorsel]

I don't believe you and your posting history never alludes to any MD only work. It does go wayy back and consistently refers to you working in a supervision model. Regardless, it's the internet, your truth can be whatever you want.

The reality is that you haven't worked MD only. You're the biggest supervision model fanboy here. Anyone who's worked in both models knows there is a difference. I'm not going to even touch on the CRNA problem. I think this field has an anesthesiologist problem, in particular those who invite and have become dependent on the supervision model. I do think, sadly, MD only work will become less and less over time and likely go away completely. The CRNAs are making that less likely though of recent as their demands become greater and greater. However, my point remains, which is that anyone who has seen and worked in both a MD only model and a supervision model absolutely knows there's a difference in the care provided.

Did you say FanBoy!!!!
I am dying laughing!!!
RONTFLMAO!!!!!

 

[OptionOffense]

Oh please. Plenty of people on here love and tout how great this system is because they make a **** ton of money off the nurses. I am talking about practice owners and partners who want to be 1:4 so that can make 700K+ instead of 500k.
Come on, these people don’t try to bring on more Doctors because that means they would have to split the pie even more. They want to keep as much money as possible.
The first person who responded to this thread is one of those people. And there are plenty more. Nobody’s forcing these people to do 1:4, they want to do this to make the most amount of money. All greed. It’s not just “the system”. They “system” was started by doctors.

Maybe 25 percent more money to supervise but 200 percent more liability. Does not compute. Not for me I dont know how you guys do it

 

[chocomorsel]

I'm curious if you've ever worked in an ACT model. Many of you clearly have not, and I know a number of you work in MD-only practices, which if you've read my posts over the years, I've always supported. But as MMan indicates, he works in the real world - as do I - and it's physically impossible for every patient to have an anesthesiologist personally perform their anesthetic. With the exception of small 1-2 person shops covering AMCs, I'm not aware of ANY MD-only practices in my state, and best I can tell, they're relatively rare in the Southeast.

Like it or not, the ACT is or can be a good solution to the problem of limited numbers of anesthesiologists. With medical direction, an anesthesiologist is personally involved with every single patient. I think my large practice does it well - 1:1 to 1:4, all day, every day, depending on patient acuity. We are 3:1 CAA to CRNA, so the mindset with our anesthetists is always medical direction anyway. We don't tolerate deviation from our practice model by any of our anesthetists, and expectations are made clear well before they start working for us. That type of work ethic comes from the docs (who do not sit in the office for hours on end - they're too busy). Our docs do all the regional, all the blocks. We follow the TEFRA requirements - period. We are currently an AMC-owned practice, but have never been pushed, coerced, or mandated to change from our medically directed way of doing things. Contrary to opinions in the ivory tower, it is quite possible to do 1:4 medical direction and do so safely. Most of the practices in our area function pretty similarly, and we have world-class private as well as academic hospitals with sterling reputations that run strictly as medically directed practices and have for decades.

There are certainly bad ACT practices out in the real world as well. "Supervision" is in name only when you're 1:10 or even worse. I know plenty of practices, including several that are pretty good sized, where the docs are nowhere to be found at nights or on weekends (and often never in OB). Those hours are totally abdicated to the CRNAs (never CAAs since we don't work in those types of practices).

Is a medically-directed ACT perfect? I guess not if you feel anything less than MD-only is the gold standard - but it is most definitely how the real world operates.

Dude, you are an AA. Chill out. Many of us like your type. You aren’t brainwashed like the CRNAs. And no, it is not possible to do 1:4 safely all the time. Shouldn’t be done at all. Midlevel skill is super variable. And some of y’all are straight up dangerous. Stop drinking the Kool aide.
However @Mman is a straight money maker who spews crap to justify his model of making a **** ton of money off CRNAs while Supervising with ratios so he can make his damn near million dollars I’m sure.

 

[chocomorsel]

Maybe 25 percent more money to supervise but 200 percent more liability. Does not compute. Not for me I dont know how you guys do it

Ask @Mman. He’s the one w the answers.

 

[Southpaw]

I currently work in a PP group ACT model that bends the rules of medical direction. It’s the culture here that the CRNAs emerge without giving you a heads-up, and not infrequently they’ll induce a patient by themselves when the anesthesiologist is tied up giving a morning or lunch break.

We also utilize SRNAs as solo providers to substitute for CRNAs in a 1:2 ratio. I know this doesn’t violate TEFRA but it’s not right.

I’m leaving for a much better group.

Thanks for being honest about your supervision reality. I don’t think it helps for people to come here and say one thing, but their reality is different.

 

[charlieyeager]

Association of Anesthesiologist Staffing Ratio With Surgical Patient Morbidity and Mortality - PubMed

This study's findings suggest that increasing overlapping coverage by anesthesiologists is associated with increased surgical patient morbidity and mortality. Therefore, the potential effects of staffing ratios in perioperative team models should be considered in clinical coverage efforts.

pubmed.ncbi.nlm.nih.gov

Some of you doing high coverage ratios may be providing worse care.

Be ready for the lawsuits. Better get consent for concurrency preop

Can we sue the hospital for allowing us to do that?

 

[aneftp]

Maybe 25 percent more money to supervise but 200 percent more liability. Does not compute. Not for me I dont know how you guys do it

It’s not just the money. It’s the workload. MD only is very tiring with 24 hour calls plus ob. My only true near miss was still working 16 hours almost non stop and had a airway problem on extubation. This was before glidescope. Usual short chubby bmi 45. Your reflexes aren’t as sharp after 16 hours solo.

The act model. Those docs would have more energy left after 16 hours. It’s the night time reflexes. It’s tiring.

So the article itself doesn’t account for how long the crnas were working. In rooms. How long the docs were working. Too many variables

 

[Pappy Van Propofol]

MD only doesn’t work for small towns. It’s hard enough to find an anesthesiologist to hire for the ACT model especially with a bad payer mix. I would love to sit my own cases all day. My stress level would go way down. But I would have to move out west and that’s just not going to happen.

 

[anesussy]

whats canadas most densely populated city? not comparable to the northeast cities or LA

The absolute ignorance of this statement lol

So the article itself doesn’t account for how long the crnas were working. In rooms. How long the docs were working. Too many variables

Yeah, I'm sure this study with a sample of 866 453 patients somehow was thrown off by all these random variables.

 

[urge]

Don’t think the results are that relevant considering it is retrospective data.

I would expect a much bigger signal if it were a real thing.

 

[jwk]

It's funny how you can be so condescending and yet, like @Mman, either totally clueless or indifferent to the fact that private practices with employed CRNAs or AAs who meet all the TEFRA steps are hilariously rare.

I get that not everyone follows the TEFRA rules. If they're medically directing, they should, because it's a ripe area for CRNA whistleblowers. My point is that it's not the total PIA some make it out to be, but it does take good organization and a commitment to doing things a certain way. My entire profession works within medically-directed ACT practices, so naturally I'm going to support that.

 

[Urzuz]

The only problem with solo md for administrators is the lack of flexibility of the model. You dont have anyone free. If anyone is free who is going to pay them. You WANT to be doing cases for the Rvus. So when an add on case comes along, when problems arise in the pacu, when intubations happen on the floor and other such things. You need a free body to handle them. Moreover, if one MD falls ill .. you close a room completely. That only has to happen once or twice for them to bring in CRNAs. WHen efficiency was not paramout 10-20 years ago it was ok, now I feel it is more catastrophic to cancel an entire days cases for a no show.
Going forward, I think the future will be expanding the roles of CAAs as midlevels and even PAs turned CAAs. There just simply is too much demand for RNs solely to become anesthetists and it just worsens the staffing shortages of the ICU RN pool. We need another avenue of staffing.

You have built-in redundancy. When emergent cases add on, either you open a room that is within the contractual obligation you have with the hospital, or if they’re running at capacity, the emergency bumps another case.

You would be shocked at how rarely “PACU issues” arise in MD only. I remember having a dedicated PACU anesthesia attending and resident in residency, and they were busy! In MD only, the PACU is considered a boring job where RNs go to retire and mentally check out since it’s mostly discharge paperwork.

And MDs don’t “call in sick” like nurses do constantly. If someone is actually sick and can’t work (exceedingly rare), once again, you have redundancy built in.

Everyone who employs their own CRNAs without even attempting to fill their group with MDs is complicit in providing subpar care for extra $ and a better lifestyle, plain and simple. I would have more respect for those that at least acknowledge this inconvenient truth rather than trying to claim equivalence or inability to recruit more physicians (especially in a desirable city like NYC)

 

[vector2]

I get that not everyone follows the TEFRA rules. If they're medically directing, they should, because it's a ripe area for CRNA whistleblowers. My point is that it's not the total PIA some make it out to be, but it does take good organization and a commitment to doing things a certain way. My entire profession works within medically-directed ACT practices, so naturally I'm going to support that.

Yes, they should be. But what you're still not getting is that all these practices where CRNAs extubate on their own or can go to sleep on their own when the anesthesiologist is tied up aren't that way due to internal anesthesia dept decision making.

It's not some failure of anesthesiologist commitment or organization. It all stems from the fact that CRNAs don't think they need these things, and combined with a structure where CRNAs are employed by the hospital and hospital administration won't risk pissing off the CRNAs (or surgeons whose cases would be delayed by staggered starts), you end up in an unwinnable situation.

Also, 1:3 (occasionally) and 1:4 (definitely) is a big pain in the ass. It can be mitigated by having 1 or 2 of your rooms be simple mac cases or getting lucky enough that inductions or emergences end up staggered, but make no mistake, the only reason we do 1:3 or 1:4 in this country is to make more money for someone.

 

[coffeebythelake]

Also, 1:3 (occasionally) and 1:4 (definitely) is a big pain in the ass. It can be mitigated by having 1 or 2 of your rooms be simple mac cases or getting lucky enough that inductions or emergences end up staggered, but make no mistake, the only reason we do 1:3 or 1:4 in this country is to make more money for someone.

100% agree with this.
especially with complicated cases doing 1:3 or 1:4 is ridiculous and substandard
as an employed physician i don't make any extra money for being extended in this way, pulled in multiple directions, running from room to room on ASA3's and 4's, it just means more money for the hospital and their administrators (and they are doing very well financially)

 

[OptionOffense]

the only reason we do 1:3 or 1:4 in this country is to make more money for someone.

Yes, that and to facilitate cases otherwise you would not be able to get nearly as many cases done. I recognize that even though working with CRNAs is not part of my mindset right now. There are some places that have 85 crnas and 19 docs show up in the morning. You would be interviewing for 5-7 straight years to get 85 docs to sign on to do ALL MD and thats if there is no attrition amongst the docs.

 

[Southpaw]

Yes, they should be. But what you're still not getting is that all these practices where CRNAs extubate on their own or can go to sleep on their own when the anesthesiologist is tied up aren't that way due to internal anesthesia dept decision making.

It's not some failure of anesthesiologist commitment or organization. It all stems from the fact that CRNAs don't think they need these things, and combined with a structure where CRNAs are employed by the hospital and hospital administration won't risk pissing off the CRNAs (or surgeons whose cases would be delayed by staggered starts), you end up in an unwinnable situation.

Also, 1:3 (occasionally) and 1:4 (definitely) is a big pain in the ass. It can be mitigated by having 1 or 2 of your rooms be simple mac cases or getting lucky enough that inductions or emergences end up staggered, but make no mistake, the only reason we do 1:3 or 1:4 in this country is to make more money for someone.

Spot on. Nailed it.

 

[vector2]

Yes, that and to facilitate cases otherwise you would not be able to get nearly as many cases done.

You’re right, but cranking out cases like the OR is some meat grinder shouldn’t be the goal in and of itself. It’s why surgeons don’t have 4 first assists doing surgery while they float room to room pretending like they’re substantively involved.

 

[OptionOffense]

You’re right, but cranking out cases like the OR is some meat grinder shouldn’t be the goal in and of itself. It’s why surgeons don’t have 4 first assists doing surgery while they float room to room pretending like they’re substantively involved.

Listen, I totally get it. You or I didn't invent this system. It is totally fubar'd. Laissez= faire supervision is dangerous. BUt alas this is what we have. We can change it but there is absolutely no political will amongst us to be able to pull it off. So the only way I see to solve it for me is to NOT get involved with supervision at all ever.

 

[OptionOffense]

And no, it is not possible to do 1:4 safely all the time.

I think it CAN be done safely if you have staggered starts 15 mins apart and the rooms are close to each other and the mid-level follows your direction to a 'T" with no lippiness or this bull**** Im a crna im equal to you and studies show no difference. WIth those lippy crnas, NO it is not safe because they are rogue and useless to you. All you are doing all day is worrying about the stupidity they will do which will lead to unsafe care burnout and make your day a living nightmare. . So I agree in this situation it is NOT safe. BUt it CAN be if they accept direction.

 

[pirate_doc]

I'm a newish grad 2 years out of fellowship and work in a MD only group in Portland. As discussed here it's a pay cut but mattered to me. Fact of the matter is you're a better anesthesiologist doing your own cases. Being completely on your own, having to do everything on your own makes you fierce. We all ignore like we can't tell the difference in active skills working with anesthesiologists that supervise and those that don't. It's obvious. Anyone arguing otherwise is delusional about the degradation of their skills from supervising. **** can go down in a "routine" lap chole just as in an esophagectomy. But hey thanks to the retiring generation for ****ing the field over, enjoy your beach house and Maserati.

 

[Teillard]

Where are all the rioting surgeons? Are anesthesiologists the only doctors in the OR that have scruples or see a problem with bad outcomes? Dismissing the surgeons as just caring about their bottom line as a reason for their relative silence is a bit begging the question. They're the ones seeing patients in their clinics day in and day out, not anesthesiologists who mostly discharge from the PACU never to see the patient again.

Parsing the political from the clinical and employment issues of supervision/direction across the United States is the trick and if this conversation is any indication, it won't happen any time soon.

 

[anbuitachi]

Lot of people come up with reasons things can't be MD only. Honestly sounds like BS to me. They can hire a surgeon for a small town but can't hire anesthesiologist? Maybe pay more???? I don't ever see surgeons say , we need to supervise nurses 4 to 1 in rural areas for cases cause md only will never work.

Also what happens when a surgeon calls out? One of the surgeons called out the other day and the cases were cancelled. Not ideal but not a huge deal either. Reschedule them.

 

[anbuitachi]

Where are all the rioting surgeons? Are anesthesiologists the only doctors in the OR that have scruples or see a problem with bad outcomes? Dismissing the surgeons as just caring about their bottom line as a reason for their relative silence is a bit begging the question. They're the ones seeing patients in their clinics day in and day out, not anesthesiologists who mostly discharge from the PACU never to see the patient again.

Parsing the political from the clinical and employment issues of supervision/direction across the United States is the trick and if this conversation is any indication, it won't happen any time soon.

There are definitely good surgeons out there but many of the surgeons definitely won't be jumping on this bandwagon. Many don't care. Others want the money. Think about how many times surgeons argue about proceeding w the case just because they don't want to mess up their day when we tell them it's not good for the patient.

 

[coffeebythelake]

There are definitely good surgeons out there but many of the surgeons definitely won't be jumping on this bandwagon. Many don't care. Others want the money. Think about how many times surgeons argue about proceeding w the case just because they don't want to mess up their day when we tell them it's not good for the patient.

Surgeons just want to cut. Very few actually care about whats best for the patient.

 

[coffeebythelake]

Where are all the rioting surgeons? Are anesthesiologists the only doctors in the OR that have scruples or see a problem with bad outcomes? Dismissing the surgeons as just caring about their bottom line as a reason for their relative silence is a bit begging the question. They're the ones seeing patients in their clinics day in and day out, not anesthesiologists who mostly discharge from the PACU never to see the patient again.

Haven't you seen all the memes about "blame anesthesia?" There is some truth to this. Most surgeons don't care too much about the increased risk of complication, when they can just point the finger at the faceless person doing the anesthesia and say it is their fault. Hell, there are some piece of **** surgeons that blame anesthesia for things that are clearly surgical errors and complications.

 

[Zekchar]

Parsing the political from the clinical and employment issues of supervision/direction across the United States is the trick and if this conversation is any indication, it won't happen any time soon.

Medical malpractice is the great equalizer. The standard for sharp MD only practice docs is the same as for MD supervisors of 4 CRNAs. Eventually those 1:4 ratios will have a bad outcome to someone of importance and then the curtain will be lifted. We need more Joan Rivers cases, or more specifically, more publicity regarding bad anesthesia outcomes. Most bad outcomes and closed claims are shielded from the public eye. We have simply been too good at saving patients from CRNA malpractice and everyone moves on due to no harm, no foul.

Remember when there was that bad outcome in Walnut Creek and the publicity it had due to the child dying? Just wait until people stop settling lawsuits, which allows all parties involved to deny any blame and hush money is paid out to the injured party or family. Wait until people demand loud and televised/recorded jury trials where CRNAs are forced to defend their "I always do things this way, irrespective of the age and comorbidities of the patient in front of me" practice. The population is getting older, sicker, and more and more cases are being done. It's innevitable. One multimillion dollar lawsuit due to negligent CRNA practice in a random hospital undoes 5+ years of "going withthe cheap CRNAs vs physicians salaries."

I have a bold prediction that sometime in the near future, a study will come out that is similar to "To Err is Human." It will be a followup to that study which will explore the outcomes between Physicians vs Physicians supervising Physician Extendors (PAs, CRNAs, NPs) vs Physician Extendors only. The results will be ugly for our non-physician "colleagues" and patients will demand physician only care. I'll happily be there to provide it ... for the right price.

 

[Hoya11]

Lot of people come up with reasons things can't be MD only. Honestly sounds like BS to me. They can hire a surgeon for a small town but can't hire anesthesiologist? Maybe pay more???? I don't ever see surgeons say , we need to supervise nurses 4 to 1 in rural areas for cases cause md only will never work.

Also what happens when a surgeon calls out? One of the surgeons called out the other day and the cases were cancelled. Not ideal but not a huge deal either. Reschedule them.

yeah but you see them use PAs to move volume through their clinic.. not the same thing?

 

[anbuitachi]

yeah but you see them use PAs to move volume through their clinic.. not the same thing?

We Midlevel pa and np in our preop clinic. Not the same thing

 

[vector2]

Medical malpractice is the great equalizer. The standard for sharp MD only practice docs is the same as for MD supervisors of 4 CRNAs. Eventually those 1:4 ratios will have a bad outcome to someone of importance and then the curtain will be lifted. We need more Joan Rivers cases, or more specifically, more publicity regarding bad anesthesia outcomes. Most bad outcomes and closed claims are shielded from the public eye. We have simply been too good at saving patients from CRNA malpractice and everyone moves on due to no harm, no foul.

Remember when there was that bad outcome in Walnut Creek and the publicity it had due to the child dying? Just wait until people stop settling lawsuits, which allows all parties involved to deny any blame and hush money is paid out to the injured party or family. Wait until people demand loud and televised/recorded jury trials where CRNAs are forced to defend their "I always do things this way, irrespective of the age and comorbidities of the patient in front of me" practice. The population is getting older, sicker, and more and more cases are being done. It's innevitable. One multimillion dollar lawsuit due to negligent CRNA practice in a random hospital undoes 5+ years of "going withthe cheap CRNAs vs physicians salaries."

I have a bold prediction that sometime in the near future, a study will come out that is similar to "To Err is Human." It will be a followup to that study which will explore the outcomes between Physicians vs Physicians supervising Physician Extendors (PAs, CRNAs, NPs) vs Physician Extendors only. The results will be ugly for our non-physician "colleagues" and patients will demand physician only care. I'll happily be there to provide it ... for the right price.

I love the optimism, but I fully expect the status quo wherein hospitals just brush mid-level fckups under the rug to continue. And I fully expect all the other not-devastating-but-not-that-great-either stuff to continue flying under the radar too. The other day had an EP ablation on a 25yo woman. As the tube goes in I get called away to another room. Experienced locum CRNA in there (10+ yrs exp) with a SRNA and we need an aline for the case so they get started on it. I get tied up and eventually when I make it back I see that between the two of them they've trackmarked both this poor lady's wrists....because the CRNA apparently doesn't know how to use ultrasound. The EP walks over and starts tapping his foot and of course I take look with the US and she's got a beautiful artery mid forearm and the line is in in 5 secs.

The thing is, this wasn't really a bad outcome here, per se. Short of a temporary radial nerve palsy the worst thing that happened to the pt was cosmetic + a bit of wrist soreness. But as long as the only thing that matters is whether the patient goes to sleep and wakes up (which given how safe anesthesia is nowadays even the most incompetent CRNAs usually don't kill anyone), the multitude upon multitude of this sort of bumbling, inept, inartful anesthesia care will get a pass.

 

[anbuitachi]

I love the optimism, but I fully expect the status quo wherein hospitals just brush mid-level fckups under the rug to continue. And I fully expect all the other not-devastating-but-not-that-great-either stuff to continue flying under the radar too. The other day had an EP ablation on a 25yo woman. As the tube goes in I get called away to another room. Experienced locum CRNA in there (10+ yrs exp) with a SRNA and we need an aline for the case so they get started on it. I get tied up and eventually when I make it back I see that between the two of them they've trackmarked both this poor lady's wrists....because the CRNA apparently doesn't know how to use ultrasound. The EP walks over and starts tapping his foot and of course I take look with the US and she's got a beautiful artery mid forearm and the line is in in 5 secs.

The thing is, this wasn't really a bad outcome here, per se. Short of a temporary radial nerve palsy the worst thing that happened to the pt was cosmetic + a bit of wrist soreness. But as long as the only thing that matters is whether the patient goes to sleep and wakes up (which given how safe anesthesia is nowadays even the most incompetent CRNAs usually don't kill anyone), the multitude upon multitude of this sort of bumbling, inept, inartful anesthesia care will get a pass.

wait what? the arterial itself can die /clot off if you poke it 20 times with holes and hematoma everywhere

if i were a patient, and i woke up with trackmarks on my arms, id be pretty unhappy because i know they stabbed my artery a lot and i def dont waant that

 

[Southpaw]

if i were a patient, and i woke up with trackmarks on my arms, id be pretty unhappy because i know they stabbed my artery a lot and i def dont waant that

You know better though. The problem inherent to anesthesia is, most people don't know any better. This is a decent sized reason why I would have chosen another field given the choice again. None of my patients wake up knowing how well, or how poorly, my job was done in most instances. They chalk it up to 'it's just how i react to anesthesia'. Most likely your trackmarked patient wakes up with a sore arm and says to themself 'oh well I'm sure they tried their best'. There are 100s of possible scenarios, like @vector2 described, where our 'equal provider' mucks around or botches something up for 10-15 minutes and either eventually lucks up and gets it, gets flustered and quits until we are able to make it back to the room and help them, or we step in quickly and fix the situation. Everyone here knows what I'm talking about I'm sure. Everyone here knows this isn't ideal or optimal care when it occurs. Patients wake up knowing no better, because they don't have the knowledge base to know any better. Hospital meat grinding gears just continue to slowly churn along not caring anything whatsoever about the actual quality of care so long as no one makes a fuss and JCAHO gives them a check mark for wearing endless and increasing layers of useless PPE.

 

[nimbus]

Medical malpractice is the great equalizer. The standard for sharp MD only practice docs is the same as for MD supervisors of 4 CRNAs. Eventually those 1:4 ratios will have a bad outcome to someone of importance and then the curtain will be lifted. We need more Joan Rivers cases, or more specifically, more publicity regarding bad anesthesia outcomes. Most bad outcomes and closed claims are shielded from the public eye. We have simply been too good at saving patients from CRNA malpractice and everyone moves on due to no harm, no foul.

Remember when there was that bad outcome in Walnut Creek and the publicity it had due to the child dying? Just wait until people stop settling lawsuits, which allows all parties involved to deny any blame and hush money is paid out to the injured party or family. Wait until people demand loud and televised/recorded jury trials where CRNAs are forced to defend their "I always do things this way, irrespective of the age and comorbidities of the patient in front of me" practice. The population is getting older, sicker, and more and more cases are being done. It's innevitable. One multimillion dollar lawsuit due to negligent CRNA practice in a random hospital undoes 5+ years of "going withthe cheap CRNAs vs physicians salaries."

I have a bold prediction that sometime in the near future, a study will come out that is similar to "To Err is Human." It will be a followup to that study which will explore the outcomes between Physicians vs Physicians supervising Physician Extendors (PAs, CRNAs, NPs) vs Physician Extendors only. The results will be ugly for our non-physician "colleagues" and patients will demand physician only care. I'll happily be there to provide it ... for the right price.

There were no CRNAs involved in either of those cases (Joan Rivers or Walnut Creek) so not great examples.

 

[chocomorsel]

It’s not just the money. It’s the workload. MD only is very tiring with 24 hour calls plus ob. My only true near miss was still working 16 hours almost non stop and had a airway problem on extubation. This was before glidescope. Usual short chubby bmi 45. Your reflexes aren’t as sharp after 16 hours solo.

The act model. Those docs would have more energy left after 16 hours. It’s the night time reflexes. It’s tiring.

So the article itself doesn’t account for how long the crnas were working. In rooms. How long the docs were working. Too many variables

Dude. I have done both. And do you know what? They both suck.
The problem with being tired and not having proper reflexes is not the model. The problem is the 24 hour call. Running around taking 17000 steps, doing blocks and assessments in a 1:4 busy ACTmodel is tiring as hell.

 

[nimbus]

I do my own cases about 30% of the time and medically direct the rest of the time. Those solo days are a walk in the park compared to my medical direction days. I get to enjoy the intellectual stimulation that comes with managing sup-optimal anesthetics administered by overconfident anesthesia nurses. I feel like medically directing keeps me sharp in a different way than working solo does. More patients per day means more complications means more thinking about how to quickly work through a differential and manage it quickly.

I'm not trying to win the anesthesia Olympics or anesthesia-Jeopardy, just pointing out that there are challenges associated with medical direction that keeps me sharper than just working solo. This isn't an argument for medical direction, just an observation. Working with ****ty surgeons will make you a better anesthesiologist in some ways, but I'd rather work with good ones (which will make you better in other ways).

For what it's worth I had to do a nerve block for an older doc the other day who has been working solo MD in a crappy community hospital for decades because he "hasn't done a nerve block in years."

The older doc must not be compensated by unit production

 

[Urzuz]

I do my own cases about 30% of the time and medically direct the rest of the time. Those solo days are a walk in the park compared to my medical direction days. I get to enjoy the intellectual stimulation that comes with managing sup-optimal anesthetics administered by overconfident anesthesia nurses. I feel like medically directing keeps me sharp in a different way than working solo does. More patients per day means more complications means more thinking about how to quickly work through a differential and manage it quickly.

I'm not trying to win the anesthesia Olympics or anesthesia-Jeopardy, just pointing out that there are challenges associated with medical direction that keeps me sharper than just working solo. This isn't an argument for medical direction, just an observation. Working with ****ty surgeons will make you a better anesthesiologist in some ways, but I'd rather work with good ones (which will make you better in other ways).

For what it's worth I had to do a nerve block for an older doc the other day who has been working solo MD in a crappy community hospital for decades because he "hasn't done a nerve block in years."

I’ve posted this before, but I will post it again:

Supervising cases is more challenging for ALL THE WRONG REASONS. The anesthetic management isn’t more challenging, it’s that you have to worry about if your RN is appropriately fed and watered, if the patient isn’t coding next door and you haven’t gotten a phone call, biting your tongue when you know they chose a less-than-ideal anesthetic plan but you don’t want to hurt their feelings so you let them do it their way.

Yeah, if those elements are what make supervisory jobs more challenging, by means you all should pat yourselves on the backs for doing something that the average PP MD-only anesthesiologist can’t

 

[anbuitachi]

You know better though. The problem inherent to anesthesia is, most people don't know any better. This is a decent sized reason why I would have chosen another field given the choice again. None of my patients wake up knowing how well, or how poorly, my job was done in most instances. They chalk it up to 'it's just how i react to anesthesia'. Most likely your trackmarked patient wakes up with a sore arm and says to themself 'oh well I'm sure they tried their best'. There are 100s of possible scenarios, like @vector2 described, where our 'equal provider' mucks around or botches something up for 10-15 minutes and either eventually lucks up and gets it, gets flustered and quits until we are able to make it back to the room and help them, or we step in quickly and fix the situation. Everyone here knows what I'm talking about I'm sure. Everyone here knows this isn't ideal or optimal care when it occurs. Patients wake up knowing no better, because they don't have the knowledge base to know any better. Hospital meat grinding gears just continue to slowly churn along not caring anything whatsoever about the actual quality of care so long as no one makes a fuss and JCAHO gives them a check mark for wearing endless and increasing layers of useless PPE.

True. We actually had a patient complain once about bilateral arterial line track marks on both wrists. It was presented at the monthly department meeting as well! Not my patient though so I don't know the details. There must've been close to 20 pokes