Barbarians at the Gate

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
Naah. The point of necrobumping this was to figure out what has been done in three years since that was published. Having known Warren personally and having interviewed at Vandy, it was obvious that he was setting up this stuff there. Remember the remote OR monitoring etc? The closed loop patient monitoring systems were shown to us by Khaterpal's boss, Kevin Tremper. So, the systems are beginning to show up, its just that the human is still there. Sandberg makes a very valid point that the market will lead to this being mechanized. Patients still prefer MDs over CRNAs. Yet, CRNA- only groups are not a rarity anymore. The anesthesiologist will still be needed for one thing or another - but how the field will evolve is what needs to be seen. They money is not in turning the dial for sevo, the money is in something else.,what, I don't know yet but we'll figure it out. No, it aint in derm, either. DNPs with derm 'fellowships' will be taking over all their bread n butter cases in 10 years time.
 
dr doze said:
This was a recruitment tool for prospective residents?
Click to expand...

Not sure if it was meant to be a recruitment tool or just a "heads up" that this would be the departmental outlook at Vandy moving forward (I realize he doesn't really speak for every attending at the institution, but it does mean something coming from the chair); what I do know is that all the interviewees walked out of there that day exchanging some sideways glances. And more than a little conversation about it on the bus back to the hotel. I'm still unsure how I feel about it (though others can and have debated the merit of this particular type of thinking on this forum).
 
NightNight said:
Not sure if it was meant to be a recruitment tool or just a "heads up" that this would be the departmental outlook at Vandy moving forward (I realize he doesn't really speak for every attending at the institution, but it does mean something coming from the chair); what I do know is that all the interviewees walked out of there that day exchanging some sideways glances. And more than a little conversation about it on the bus back to the hotel. I'm still unsure how I feel about it (though others can and have debated the merit of this particular type of thinking on this forum).
Click to expand...

This means the guy is confident that Medical Students will choose Vanderbilt anyway as the MATCH is very tight these days for spots. If you don't go to Vanderbilt someone else will gladly match there as the alternative is far worse.

The new Chairman is free to begin his vision for anesthesia care the "cost efficient" way.
 
BLADEMDA said:
This means the guy is confident that Medical Students will choose Vanderbilt anyway as the MATCH is very tight these days for spots. If you don't go to Vanderbilt someone else will gladly match there as the alternative is far worse.

The new Chairman is free to begin his vision for anesthesia care the "cost efficient" way.
Click to expand...

👍
 
"This is an opportunity to leverage technology to become more efficient in our use of personnel and their intellect. Seizing this opportunity implies that we should regard technologies, such as anesthesia information management systems, decision support tools, closed-loop control for drug administration, as well as new care team models as the topics of enthusiastic research and development. Choosing this course moves OR and procedure room anesthesiology closer to the model used in intensive care units, where anesthesiologists assure that care is provided, but only personally provide care when their unique skills cannot be replaced."

Sandberg is goint to use a 4:1 model instead of the current one which will save his Department Millions of dollars per year.
 
BLADEMDA said:
Sandberg is goint to use a 4:1 model instead of the current one which will save his Department Millions of dollars per year.
Click to expand...
They do strongly feel that supervision of mid levels by anesthesiologists is the future and actively promote learning that during residency.
 
So, under this increased supervisory model, what skill set can we obtain which will make us better?? Better advanced airway, better ACLS (come on....), better quick troubleshooting skills (either have it or you don't).

I don't want to be a hands off attending. Sure, our time isn't best spent stool sitting, but over a 25 year career, if the ONLY stool sitting one does is during residency, well I would think that one is going to seriously lose the flow of the room.

You simply can NOT be dialed into the flow of 6 rooms. It's not possible and if the academic "thought leaders" amongst us want to promote that, well, they're only fooling themselves while sipping a Starbucks in the Ivory Tower. I call BS to that notion.

Do we need to reinvent ourselves in ways in which we can add value in a changing environment? Sure, but I'm not sure a 1:6 or 1:8 ratio is the answer.
 
gasattack3 said:
So, under this increased supervisory model, what skill set can we obtain which will make us better?? Better advanced airway, better ACLS (come on....), better quick troubleshooting skills (either have it or you don't).

I don't want to be a hands off attending. Sure, our time isn't best spent stool sitting, but over a 25 year career, if the ONLY stool sitting one does is during residency, well I would think that one is going to seriously lose the flow of the room.

You simply can NOT be dialed into the flow of 6 rooms. It's not possible and if the academic "thought leaders" amongst us want to promote that, well, they're only fooling themselves while sipping a Starbucks in the Ivory Tower. I call BS to that notion.

Do we need to reinvent ourselves in ways in which we can add value in a changing environment? Sure, but I'm not sure a 1:6 or 1:8 ratio is the answer.
Click to expand...

Agreed. 👍
 
gasattack3 said:
Do we need to reinvent ourselves in ways in which we can add value in a changing environment? Sure, but I'm not sure a 1:6 or 1:8 ratio is the answer.
Click to expand...
The focus of his editorial was not that we should learn to supervise 10 people. He was emphasizing that crnas will be redundant because the cheapest (and arguably safest) option is to have automated systems deal with the lower end, ASA-I,II cases. Some still think that this concept is delusional, but for that matter many also thought that self driving cars were never going to be a reality. The CRNA supervisory model is just an interim solution that is relevant to the next 10-20 years. In the long term, things will be automated for most part. What will be role of the anesthesiologist then? That's the question..crnas and srnas are not the focus of what he is saying.
 
What about one guy "overseeing" 6 or 8 rooms (i.e. mostly preoping and darting in and out of rooms) while the other anesthesiologists are doing ASA 3/4 cases and other high risk procedures??

That's more a model which I can see. This way, "efficiency" prevails and profitability is maintained by the few "lucky" enough to run 6 or 8 ASA 1/2 rooms while the others maintain their skills by doing cases (with a modified/glorified assistant?? Like a well trained TECH?) which DO require the breadth of our skills.

This fight is not lost. Do NOT teach regional, TEE, interventional pain etc and SHAME the hell out of any "colleague" who does.
 
There was never a fight and never will be. Evolution is the only way we can survive. If you don't teach them, someone else will.
 
Noegrus said:
There was never a fight and never will be. Evolution is the only way we can survive. If you don't teach them, someone else will.
Click to expand...

I agree with the last sentence, perhaps. But, not the first. There is indeed a fight going on, whether we want to admit it or not.


I do see your point about evolution. But, we need to make sure we get it right and we haven an opportunity, maybe, to shape the way our field evolves. Better that than what the AANA is doing to us right now. Our margin for error grows smaller by the year.

When said and done, like many others have said, we can worry about all of this stuff until the cows come home. OR, we can do our best to help our field "evolve" in a way which is NOT suicidal and get on with our careers and life (Sevo said this rather eloquently not long ago).
 
By the way, what type of servo system is there on these supposed machines?

Automating this stuff shouldn't be technically THAT difficult. It will incorporate some expensive automation EQUIPMENT however.

I see a closed loop system using some sort of EEG monitoring (say BIS for now) or at least to MAC. This feedsback to an automated gas "dialer". Ofcourse, there's always hemodynamic issues which could be dealt with via BP input and pressor output or fluid administration (or both), all the while considering the overall picture. Twitch monitoring is looped back to an infusion pump of NMBD of choice.

This is practical but probably only for long cases (greater than 3 hours?)

Failsafes will clearly need to be designed in and I'm not sure how that will be done but it's possible. I suppose a human could aways run and and go "manual" if something faults out which can't readily be rectified.

It's a very interesting concept indeed. This will take a massive paradigm shift, however, and I'm still not convinced of it's cost effectiveness, notwithstanding increasingly lower "prices" for these systems as would be expected to occur.

Even the Divinci still requires ONE surgeon (at least) manning the controls. Could ONE anesthesiologist "man" multiple machines in multiple rooms?

Would the cost effectiveness of losing the stool sitter be outweighed by adding a tech or two, and justify the expense of the equipment not to mention the SET UP time required?

Even the most nimble robots which are commercially available would cause a design engineer serious pause as pertains to HUMAN interface versus machines and hardware....... So, would the airway (not that airway variability couldn't be addressed a vision system with some very sophisticated programming) then, remain the domain of the human?

Man, I just don't know. This seems a WAYS off, like maybe not even in most RESIDENTS careers.
 
gasattack3 said:
So, under this increased supervisory model, what skill set can we obtain which will make us better?? Better advanced airway, better ACLS (come on....), better quick troubleshooting skills (either have it or you don't).

I don't want to be a hands off attending. Sure, our time isn't best spent stool sitting, but over a 25 year career, if the ONLY stool sitting one does is during residency, well I would think that one is going to seriously lose the flow of the room.

You simply can NOT be dialed into the flow of 6 rooms. It's not possible and if the academic "thought leaders" amongst us want to promote that, well, they're only fooling themselves while sipping a Starbucks in the Ivory Tower. I call BS to that notion.

Do we need to reinvent ourselves in ways in which we can add value in a changing environment? Sure, but I'm not sure a 1:6 or 1:8 ratio is the answer.
Click to expand...


As a Resident you need to physically do as many cases as possible from start to finish. Even as a junior attending it helps to do 50/50 (supervise vs sit ) for at least the first few years. It makes you a better Anesthesiologist and a better Attending.
 
There are two major unsolved technical obstacles: artificial intelligence and machine vision.
Automated systems are fabulous at linear thinking, i.e. algorithms. However, they are not at all good with the abstract. Medicine in general and anesthesia in particular are turning into algorithm-based management approaches for human disease. So, automated closed loop systems should, in theory, work well here. After all, the EKG machine does read the EKG better than the physician. Now, can it integrate the rest of the patient's info and find the best management algorithm? Not till AI comes of age. It will, in due time.
Airway management is impaired principally by the key issue in computer vision: the computer can not figure out what lies in the shadows. Through millions of years of evolution, the mammalian eye and brain have no problem in dealing with shadows. That is a major reason hampering fully automated surgical equipment - the damn thing can't see anything on its own.
Will these issues be solved? Absolutely. When? I don't know. Anesthesia doesnt traditionally attract engineers and computer scientists, but therr is money to be made in automation and I can bet you that folks are already working on this stuff in the industry. But whenever it happens, a LOT of crnas are gonna go without jobs. I'd give it another 10 years.
 
Noegrus said:
There are two major unsolved technical obstacles: artificial intelligence and machine vision.
Automated systems are fabulous at linear thinking, i.e. algorithms. However, they are not at all good with the abstract. Medicine in general and anesthesia in particular are turning into algorithm-based management approaches for human disease. So, automated closed loop systems should, in theory, work well here. After all, the EKG machine does read the EKG better than the physician. Now, can it integrate the rest of the patient's info and find the best management algorithm? Not till AI comes of age. It will, in due time.
Airway management is impaired principally by the key issue in computer vision: the computer can not figure out what lies in the shadows. Through millions of years of evolution, the mammalian eye and brain have no problem in dealing with shadows. That is a major reason hampering fully automated surgical equipment - the damn thing can't see anything on its own.
Will these issues be solved? Absolutely. When? I don't know. Anesthesia doesnt traditionally attract engineers and computer scientists, but therr is money to be made in automation and I can bet you that folks are already working on this stuff in the industry. But whenever it happens, a LOT of crnas are gonna go without jobs. I'd give it another 10 years.
Click to expand...

Very Funny. As a person who predates cell phones I can tell you this "technology" screws up rather frequently. I would not trust a patient's life to an automated system made in China
Even the new anesthesia machines (which are technological marvels) are inferior to the battle hardened, tank like Narkomeds of old. The new machines are awesome technological advances but require more maintenance and break more frequently.

Newer is not always better or safer. We have long way to go before automated systems are used routinely. I agree it will happen but not for at least 20 years.
 
Last edited:
Let's not all forget that even if this technology magically existed in perfect working order tomorrow, it would still be a long time off from being used due to regulatory roadblocks. If it takes 5 years to get a experimental drug approved to test in mice, how long will it take to get a trial of automated machines keep human beings alive in surgery?
 
Not happening tomorrow, that's for sure. 10 years? 20? Probably. More of a 'future challenge' than what-to-cook-for-dinner kinda issue. Hopefully, by then cars should be automated and traffic more organized so we'd not have to spend an hour and a half trying to get back home at the end of the day. 🙁
 
How few anesthesiologists can we get away with?

That is the question that the medical specialty of anesthesia has been fighting and will be fighting for the foreseeable future.

Some of our membership have taken the nontraditional position and said, "a lot less".


Nobody is objective. Everybody in this profession (myself included) and the nurse aneshetists have an agenda. There are several professorships and careers to be made for addressing this "public policy" or "allocation of resources" initiative. a.k.a. selling out.

The CRNAs are not as good. Period. I hate them for not admitting that. I hate them for saying that what I do every day doesn't matter. I hate administrators, legislators, and these academic cockroaches for not admitting that they are making a cost/benefit decision. Maybe it should be made. But don't lie and say that you are not compromising. Pretending to "hold the line" on quality while saving on expenses.

F**k em all.
 
dr doze said:
How few anesthesiologists can we get away with?

That is the question that the medical specialty of anesthesia has been fighting and will be fighting for the foreseeable future.

Some of our membership have taken the nontraditional position and said, "a lot less".


Nobody is objective. Everybody in this profession (myself included) and the nurse aneshetists have an agenda. There are several professorships and careers to be made for addressing this "public policy" or "allocation of resources" initiative. a.k.a. selling out.

The CRNAs are not as good. Period. I hate them for not admitting that. I hate them for saying that what I do every day doesn't matter. I hate administrators, legislators, and these academic cockroaches for not admitting that they are making a cost/benefit decision. Maybe it should be made. But don't lie and say that you are not compromising. Pretending to "hold the line" on quality while saving on expenses.

F**k em all.
Click to expand...

:nod::claps::clap:😍
 
dr doze said:
How few anesthesiologists can we get away with?


Nobody is objective. Everybody in this profession (myself included) and the nurse aneshetists have an agenda. There are several professorships and careers to be made for addressing this "public policy" or "allocation of resources" initiative. a.k.a. selling out.

The CRNAs are not as good. Period. I hate them for not admitting that. I hate them for saying that what I do every day doesn't matter. I hate administrators, legislators, and these academic cockroaches for not admitting that they are making a cost/benefit decision. Maybe it should be made. But don't lie and say that you are not compromising. Pretending to "hold the line" on quality while saving on expenses.

F**k em all.
Click to expand...

Now that is some real ****.

F**k em all. 👍👍
 
dr doze said:
F**k em all.
Click to expand...

Perhaps the best one-line summary.

Some people just have their head stuck so deep in their a*s that the only thing that will influence their decisions is money. Screw patient safety and screw quality of patient care.
 
pgg said:
Strong AI is like cold fusion, it's always 20 years away.
Click to expand...

Hah. That's so true. But there have been some real strides towards AI. When mainstream media starts covering it as more than some sci-fi geek's wet dream, you know we're getting closer.

On another note, people are beginning to resemble machines. We all have to recharge something each night, update software, etc., steadily spending more time focusing on ourselves and digital content while we ignore those standing right next to us.

Maybe there is a race to the middle.

/oldmanrant
 
The problem with the f.ckheads advocating a "lot less" approach (this contrasts with those on here whom are realists and admit that this COULD be the future) is that it's akin to a "supersurgeon" who oversees, for example, 6-8 OR's everyday.

This supersurgeon reigns over the domain (individual OR's) of, say, PA's. Now, MOST of the time the PA's do just fine. The appy or gallbladder comes out, the hernia is fixed. After all, it's not exactly rocket science and much of it is just mundane work.

However, SOME of the time the supersurgeon needs to give more (or less) direction to these PA "surgeons". Sometimes he downright needs to bail them out or save them from themselves. This benefits everyone.

But, over time, the PA's do learn from their mistakes and continue on in the OR. What's to prevent the supersurgeon from losing his skillset?? How long after "supersurgeon training" will it take under a supervisory role of 6-8 rooms will he lose the ability to pop in and troubleshoot??

Can he even be considered a "supersurgeon" when he spends increasingly less time managing the flow of a case? When will he totally lose the flow of any case (thus his worth) as he supervises 6 or 8 rooms everyday.

Before, supersurgeon dude was able to get his hands dirty and scrub in for complicated parts of any given procedure. But, now, with 8 rooms, he hardly has a chance.

************************************************
Perhaps this analogy isn't exactly spot on. I don't know.

I see ratios going up but for ASA1's and 2's, and for low risk procedures. Perhaps ratios will LESSEN for higher acuity cases and sick sick patients? I think this could be justified. We often speak of resource allocation etc. Well, our resources are needed for sick patients undergoing risky procedures. And there will be no shortage of either in our careers (residents). That much is true. And it gives me confidence that while our field is going to change, we'll have an important role to play in anesthesia delivery and (we'll see how it pans out) perioperative management.
 
What's odd to me is isn't the US pretty unique in using mid-levels to provide medical services? It seems like we're headed into unprecedented waters and are always looking for reasons to provide less training or lic. less qualified people in our health care system to cut costs that keep going up. What gives? IMO we're attacking the wrong issue. To control costs you must control care at the end of life.
 
yappy said:
What's odd to me is isn't the US pretty unique in using mid-levels to provide medical services? It seems like we're headed into unprecedented waters and are always looking for reasons to provide less training or lic. less qualified people in our health care system to cut costs that keep going up. What gives? IMO we're attacking the wrong issue. To control costs you must control care at the end of life.
Click to expand...

Good luck with that one. Bring that up and the accusations of "death panel" start flying..

Remember the Terry Schiavo case?
 
It's still a huge level to pull. ~1/2 of government money in spent during the last 6 mo of life. We should probably consider the fact that much of the sending done is low yield and may not be worth it. If you're independently wealthy and want to increase your life 1 mo by spending 1 million than that is no problem. However, should public pays be doing that?

To people that bring up the ethics of it all ... consider the opportunity cost of that spending: more defense, public ed, college scholarships, peds spending, helping the poor, more NPR funds, less debt etc. etc.

dr doze said:
Good luck with that one. Bring that up and the accusations of "death panel" start flying..

Remember the Terry Schiavo case?
Click to expand...
 
Without the "stool-sitting" how can an anesthesiologist acquire the skills (technical and diagnosis/ problem-solving) in the first place to supervise others?

We all learned from our errors and picked up minute details to better our care during residency and in our practice from being in the OR and delivering patient care, not so much from supervising others.

In regards to the ICU comparisions, the honest truth is that the ICU often has more variables so that an ICU attending will always reign supreme with his knowledge base. The culture and level of respect an ICU attending gets in his domain is vastly different than an anesthesiologist in the OR (who often has smirky CRNA's rolling their eyes at his ideas).

The OR generally speaking is more amygdala-skill related. Definitely knowledge has its place but for most cases, an experienced CRNA can get by.

Sure there are often times where I walk into the room and there are things that could have been done better but in the end, their errors often didn't have a major adverse outcome.

The best argument for anesthesiologists over mid-levels is that we are better trained and simply are the best at giving patient care in the perioperative setting, especially for complicated cases or sick patients. Aside from our superior knowledge base, part of the reason for this is the intense "stool-sitting" residency we go thru which is obviously not matched by the CRNA-mills.

Take that away from us and we become the irrelevant emperor with no clothes on.
 
You must log in or register to reply here.

Similar threads

Aether2000
Is the NLM Search Database (PubMed, Medline) At Risk of Being Filtered for Undesirable Content by the Federal Government?
Replies
4
Views
445
Goro
Goro
D
Vertebral artery dissection at the chiropractor
Replies
26
Views
3K
sloh
S
D
Watches at work
2
Replies
78
Views
5K
sevo00
S
S
Is this true at MUSC tidal health?
Replies
17
Views
3K
Aether2000
Aether2000
S
Somnia Anesthesia at Everett, WA?
Replies
20
Views
3K
caligas
C
Top