Turtlez

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In what specific ways is SRNA training inferior to resident training? Are there any procedures or cases that CRNAs aren't allowed to perform? At my institution, I see SRNAs going to the same lectures, grand rounds, M&Ms and this is making me gravely concerned. Also, most attendings don't seem to have a problem with teaching them alongside residents. I've heard and believe that when doodoo hits the fan, physicians are best equipped to handle the situation. However as a ms4, I've never witnessed this personally. In terms of residency, what should I look for in a program that'll best help me combat this threat in the future? I apologize if this comes off as incredibly naive/offensive.
 

criticalelement

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this is making me gravely concerned. .
According to the chairman of Anesthesiology a fellowship is compulsory. SO do an anesthesia residency and just to be sure do TWO fellowships. Then you will be safe for the future.

I say this tongue and cheek. The specialty and residency is changing to a more cognitive one and less technical (in the operating room.) Google Periop surgical home, Surgical home as it relates to acute pain service and Enhanced Recovery after surgery to get an idea what you are gettingyourself into. Its all NOT GOOD in my opinion
 
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Psai

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In what specific ways is SRNA training inferior to resident training? Are there any procedures or cases that CRNAs aren't allowed to perform? At my institution, I see SRNAs going to the same lectures, grand rounds, M&Ms and this is making me gravely concerned. Also, most attendings don't seem to have a problem with teaching them alongside residents. I've heard and believe that when doodoo hits the fan, physicians are best equipped to handle the situation. However as a ms4, I've never witnessed this personally. In terms of residency, what should I look for in a program that'll best help me combat this threat in the future? I apologize if this comes off as incredibly naive/offensive.
Residents always get the better cases. They learn more for a longer period with a much greater knowledge base. Do you think a high school student would learn much in a graduate course about quantum physics?
 

FollowTheMoney

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According to the chairman of Anesthesiology a fellowship is compulsory. SO do an anesthesia residency and just to be sure do TWO fellowships. Then you will be safe for the future.

I say this tongue and cheek. The specialty and residency is changing to a more cognitive one and less technical (in the operating room.) Google Periop surgical home, Surgical home as it relates to acute pain service and Enhanced Recovery after surgery to get an idea what you are gettingyourself into. Its all NOT GOOD in my opinion
The only way you can ensure that you maintain your personal level of safety or security in the profession is to be a partner in a group or to start a group. You can have 5,000 fellowships, accolades, etc and it won't matter. There are only 2 important questions: 1.) Who's calling the shots? 2.) How much do you cost me?
 

WholeLottaGame7

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In what specific ways is SRNA training inferior to resident training? Are there any procedures or cases that CRNAs aren't allowed to perform? At my institution, I see SRNAs going to the same lectures, grand rounds, M&Ms and this is making me gravely concerned. Also, most attendings don't seem to have a problem with teaching them alongside residents. I've heard and believe that when doodoo hits the fan, physicians are best equipped to handle the situation. However as a ms4, I've never witnessed this personally. In terms of residency, what should I look for in a program that'll best help me combat this threat in the future? I apologize if this comes off as incredibly naive/offensive.
It varies from institution to institution. My program would let CRNAs do spinals and lumbar epidurals (mostly on OB), and arterial lines. Never a PNB or a central line. I never even saw an SRNA until I was a CA3 at night supervising CRNAs who would occasionally have them alongside. They did go to grand rounds but did not go to our resident lectures or M&Ms.

There are a couple big differences in training. For one, the requirements for case types and procedures are waaaaay lower than for anesthesia residents. And even with that, they will frequently have to count procedures/cases that they watched or split with another SRNA. Also, SRNAs pay tuition to attend school, and thus there are financial motivations to open schools and enroll as many students as possible, even if that means the quality of applicant/product suffers.

There are many smart and very technically proficient CRNAs out there, many of whom I would certainly trust to take care of myself or a family member. But if you told me that some random CRNA that I didn't know was going to be taking care of me/family member, I'd be a little nervous just because there is such a huge variety in quality.

I think PGG said something awhile ago about the high end of the CRNA knowledge/skill bell curve overlapping with the low end of the MD bell curve, and I think that's a good description. But I also that the the CRNA bell curve is much wider and flatter.

When looking at a program with CRNAs, you should find out the answers to a couple of key questions. You want a chief or attending making the daily schedule, with resident assignments being first/best. The CRNAs should be breaking out residents for lectures, relief, etc, and not the reverse (residents will occasionally have to relieve CRNAs for call assignments, I get it). You should never be sharing a room with an SRNA. I personally wouldn't want to be sharing non-grand round lectures with SRNAs, either.

This is not to bash CRNAs. I get along well with the vast majority of them. But in an academic institution, their job should be to handle the lower-educational value clinical work and support the department's mission of resident education by getting them out for lectures, etc. In a smaller program, this might mean mostly boring cases (eyeballs, etc). At my program, there were enough cases that CRNAs still got to do big neuro, vascular, onc cases, so it probably wasn't terrible. Regardless, they get rewarded handsomely for their efforts.
 
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I was a CRNA that successfully completed my well-respected program, became certified, and worked for several years.

I left the career, in part, due to the rapid proliferation of CRNA mills that disgorge a stunning number of poorly-trained graduates who are inculcated early in their education that they are capable of the same level of functioning and critical thinking as an anesthesiologist. I was asked to precept some of these students whose knowledge base was so deficient that they resorted to spending hundreds (if not thousands) of dollars taking and re-taking the Valley Review Course and rote memorizing that company's "Anesthesia Sweat Book" and "Memory Master Cards" in hopes of increasing their chances of passing the national exam on the first attempt.

Consider that the didactics of my well-regarded program were often taught by "guest" CRNAs with no more preparation than a Master's degree and clinical experience. Exams could be passed with a quick memorization of the required reading assignments and a reasonably alert presence in lectures.

Consider that the AANA offers a three-day pain management course, costing $3,000. The very idea that a weekend workshop could possibly prepare a CRNA to function as an interventional pain management practitioner is asinine. In the organization's own words:
Purpose: The Jack Neary Advanced Pain Management I Workshop provides a combination of didactic and guided hands-on lab experience for interventional pain management techniques.
Target Audience: This workshop is being provided for CRNAs with limited experience in interventional pain management and CRNAs possibly interested in pursuing this specialty within their practice.

Consider a residency in another specialty.
 

gtb

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In what specific ways is SRNA training inferior to resident training? Are there any procedures or cases that CRNAs aren't allowed to perform?
Anesthesiology residents have first completed medical school, and the nurses have not. If you have completed medical school, the answer is obvious. If not, then it is likely that no evidence or data will persuade you that a physician is more knowledgeable.

Unskilled and unaware of it: how difficulties in recognizing one's own incompetence lead to inflated self-assessments.
Kruger J1, Dunning D.
http://www.ncbi.nlm.nih.gov/pubmed/10626367
 

TimesNewRoman

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There's an interesting phenomenon that occurs with people in professions similar to ours. Skilled laborers tend to undervalue their skills - we assume that everyone is about as smart as we are and we figure people see the see the same big picture as we do because it seems so obvious. Our jobs seem reflexive because of the comprehensive training we've received and because we are all (usually) extremely intelligent. The people less well trained tend to over-estimate their skills.

Every once in a while you'll be acutely reminded of this. A lot of times, we can do the same things, but then you see an NP/PA/CRNA that is a relatively good one do or say something leaving you thinking "what just happened?"

Remember, you spent years in the classroom learning basic anatomy, path, pharm, micro, embryology, etc. and several years in training to become an expert A lot of it seems useless, until you need it.
 
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There's an interesting phenomenon that occurs with people in professions similar to ours. Skilled laborers tend to undervalue their skills - we assume that everyone is about as smart as we are and we figure people see the see the same big picture as we do because it seems so obvious. Our jobs seem reflexive because of the comprehensive training we've received and because we are all (usually) extremely intelligent. The people less well trained tend to over-estimate their skills.

Every once in a while you'll be acutely reminded of this. A lot of times, we can do the same things, but then you see an NP/PA/CRNA that is a relatively good one do or say something leaving you thinking "what just happened?"

Remember, you spent years in the classroom learning basic anatomy, path, pharm, micro, embryology, etc. and several years in training to become an expert A lot of it seems useless, until you need it.


This is exactly why and when I knew I would not continue practicing as a CRNA. Through sheer slick-talking politics, the least-skilled, oldest CRNA of my group became the Chief of the new, independent CRNA practice model under an AMC.

While I was working, I was at least smart enough to know my limitations. Many do not, and this independent practice insanity is the greatest gift of their careers.

Disclosure: just came back to SDN after a few years away. Enrolled to finish my pre-med prereqs, but will now likely withdraw and leave health care altogether. SDN may just have saved me nine years and 250k+, so hey, thanks for keeping it real.
 
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TimesNewRoman

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This.

This is exactly why and when I knew I would not continue practicing as a CRNA. Through sheer slick-talking politics, the least-skilled, oldest CRNA of my group became the Chief of the new, independent CRNA practice model under an AMC. I was in PACU and heard one of his patients screaming from another bay. This idiot, who had NO PRIOR INDEPENDENT EXPERIENCE in PNBs, was attempting to use ultrasound to place an ISB for the sole reason that the orthopod requested it. There was no anesthesiologist on site.

I am quite sure that he had no idea what he was looking at, though he had an open textbook balanced on the block cart. He was, however, quite sure that the patient was screaming because of her fracture and not due to his needle-wielding. He didn't know what he didn't know.

While I was working, I was at least smart enough to know my limitations. Many do not, and this independent practice insanity is the greatest gift of their careers.

Disclosure: just came back to SDN after a few years away. Enrolled to finish my pre-med prereqs, but will now likely withdraw and leave health care altogether. SDN may just have saved me nine years and 250k+, so hey, thanks for keeping it real.
Dude, SDN is where people come to complain. Medicine is tough, but it's still a good gig.

Sure, we're not worshiped by patients or society, we have a hard training path, we can be sued and we work hard; but how many jobs get the pay we get while able to do something intellectually stimulating and providing a service that helps people? It's a good gig.
 

HenryH

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This.

This is exactly why and when I knew I would not continue practicing as a CRNA. Through sheer slick-talking politics, the least-skilled, oldest CRNA of my group became the Chief of the new, independent CRNA practice model under an AMC. I was in PACU and heard one of his patients screaming from another bay. This idiot, who had NO PRIOR INDEPENDENT EXPERIENCE in PNBs, was attempting to use ultrasound to place an ISB for the sole reason that the orthopod requested it. There was no anesthesiologist on site.

I am quite sure that he had no idea what he was looking at, though he had an open textbook balanced on the block cart. He was, however, quite sure that the patient was screaming because of her fracture and not due to his needle-wielding. He didn't know what he didn't know.

While I was working, I was at least smart enough to know my limitations. Many do not, and this independent practice insanity is the greatest gift of their careers.

Disclosure: just came back to SDN after a few years away. Enrolled to finish my pre-med prereqs, but will now likely withdraw and leave health care altogether. SDN may just have saved me nine years and 250k+, so hey, thanks for keeping it real.
Just out of curiosity, what AMC were you working for?
 
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Dude, SDN is where people come to complain. Medicine is tough, but it's still a good gig.

Sure, we're not worshiped by patients or society, we have a hard training path, we can be sued and we work hard; but how many jobs get the pay we get while able to do something intellectually stimulating and providing a service that helps people? It's a good gig.
.
Agreed on all points. Pretty sure the train has left the station in my situation, though. I am settled with my family in a quiet farming community, debt-free, and happy. If I pursued medicine now, I would be over 40, mentally exhausted, and financially depleted by the time I made it through.

Medicine is a good gig, no doubt. I am just too off-track.

Just out of curiosity, what AMC were you working for?
One was a local start-up modeled after Northstar in Texas. MD-CRNA collusion. I thought it was the worst gig possible and left within months. Then the group I joined was taken over by the real Northstar, and I quickly realized that the shafting I received from the first AMC was an amateur job comparatively.

I would take a job laying asphalt in a Central Texas Summer before I would work for Northstar. They are every negative thing you hear about them and more.
 
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I went to a program that had an SRNA program as well. They went to the same grand rounds, but not the same lectures as us. They would do alines and a few neuraxial blocks. They did not do central lines or peripheral nerve blocks. They would do some bigger cases, neuro or transplant with a resident. Most of them were fine, but if I had to do it over again, I would'nt go to a program that trains SRNAs.
 

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.

One was a local start-up modeled after Northstar in Texas. MD-CRNA collusion. I thought it was the worst gig possible and left within months. Then the group I joined was taken over by the real Northstar, and I quickly realized that the shafting I received from the first AMC was an amateur job comparatively.

I would take a job laying asphalt in a Central Texas Summer before I would work for Northstar. They are every negative thing you hear about them and more.
Thanks for the detailed info. The primary anesthesia group in my GA hometown sold-out to an AMC called Amsol about 4 years ago, and you may have heard that Amsol was purchased by Northstar in late 2014. However, even before Northstar bought Amsol, at least 1 (possibly 2?) of the 4 hospitals that Amsol was contracting with had transitioned to the MD/CRNA Collaboration model. Ironically enough, the small handful of CRNAs I know who are currently working for Northstar/Amsol in my area claim to be happy with the gig, as well as proud of the fact that they're working in such a practice model (in fact, they tell me that they prefer to call it the "CRNA model" because they feel that "Collaborative model" sounds too restrictive). Just out of random curiosity, can I ask what you didn't like about working under Northstar's practice model?
 

Mman

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In what specific ways is SRNA training inferior to resident training?
I believe I met nearly every single minimum case requirement for CRNA training programs after my CA-1 year and then had 2 intense years left to go.

Here are some minimum case numbers they need before graduating, and keep in mind some of these can be fudged a bit by some programs.

550 total cases
100 ASA 3/4 patients
50 patients age 65+
25 patients between ages 2-12
10 patients under age 2
30 emergency cases
100 ambulatory cases
30 OB patients (10 c-sections, 10 labor epidurals)
20 prone cases
25 lithotomy cases
5 lateral position cases
5 sitting cases
5 cranis
15 thoracic cases including 5 hearts
10 vascular cases
350 cases under GA
25 total spinals + epidurals + PNBs
25 MAC cases
25 arterial lines
5 central lines, though using the simulator can count for this number
5 fiberoptic intubations, though using the simulator can count for this number


So when you see a newly minted CRNA, keep in mind the following. They may have never once put a central line in a patient. They may have never once done a fiberoptic intubation. They may have never once taken care of a baby under 1 year of age (let alone a neonate). They may have done a total of 5 cranis and 5 hearts in their life.

And those are the people the AANA thinks she be left alone to independently take care of any patient that comes in for surgery. Really? You want your loved one having a posterior fossa crani to be taken care of by somebody that once did 5 meningiomas and has never put in a central line? It's comical. I love the ACT model and see it successfully work every single day of the week, but turning those kids loose is a recipe for assassination.
 
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Turtlez

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I believe I met nearly every single minimum case requirement for CRNA training programs after my CA-1 year and then had 2 intense years left to go.
Thanks for this info!
 

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Also, they get credit for "doing" a case if they are merely present in the room and participate in any aspect of the case. I had two SRNAs claim credit for the same CABG when one placed the arterial line, one intubated, and both watched as I did the case.
 
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] Ironically enough, the small handful of CRNAs I know who are currently working for Northstar/Amsol in my area claim to be happy with the gig, as well as proud of the fact that they're working in such a practice model (in fact, they tell me that they prefer to call it the "CRNA model" because they feel that "Collaborative model" sounds too restrictive). Just out of random curiosity, can I ask what you didn't like about working under Northstar's practice model?
The "collaborative model" is semantics for essentially independent CRNA practice. The primary aim of this model is cost-containment with little to no regard for quality care, patient safety, and appropriate oversight of CRNAs by anesthesiologists.

I might concede that there are settings in which it could be appropriate for seasoned CRNAs to work with very limited or no supervision - healthy adults undergoing minor procedures. That is not the situation with this model. It is inappropriate and unsafe to expect a single anesthesiologist to manage 6 to 8 CRNA locations with sick as **** ASA III/IV in complex cases, pedi, and OB.

Now add a weak or locums anesthesiologist + some new grad CRNAs (because the wise, competent clinicians left when the AMC took over), and a few SRNAs serving as staff and you can easily understand the flaws in this model.

I not only "didn't like" that I felt we were not doing the right thing for the patients, I hated it. I hated going to work in fear that I would be assigned a case that I do not have the depth and breadth of training to handle. I hated leaving students from mediocre programs with minimal clinical experience alone because I was needed elsewhere. I hated the expectation that I was obligated to assist other CRNAs and SRNAs when the anesthesiologist was unavailable and there was trouble.

I need to feel good about the care I provide. I also need to protect my assets. I chose to stop working rather than risk an adverse patient outcome and/or a lawsuit.

I do not care about the AANA and their agenda. I do not have the training to work in that kind of model, and no one, NO ONE, can tell me that a CRNA's education is equal to an anesthesiologist's education.

I believe I met nearly every single minimum case requirement for CRNA training programs after my CA-1 year and then had 2 intense years left to go.

So when you see a newly minted CRNA, keep in mind the following. They may have never once put a central line in a patient. They may have never once done a fiberoptic intubation. They may have never once taken care of a baby under 1 year of age (let alone a neonate). They may have done a total of 5 cranis and 5 hearts in their life.

And those are the people the AANA thinks she be left alone to independently take care of any patient that comes in for surgery. Really? You want your loved one having a posterior fossa crani to be taken care of by somebody that once did 5 meningiomas and has never put in a central line? It's comical. I love the ACT model and see it successfully work every single day of the week, but turning those kids loose is a recipe for assassination.
Accurate. I graduated amongst the top in my class from a nationally-known, well-respected program having never placed a central line or PNB. No fiberoptic. Heart rotation observation only. Made neuro and thoracic numbers by doubling up. No infants < one year. This is NOT uncommon, but it is the reason why CRNA and anesthesiologist training cannot be equated. In my opinion, it is also the reason why independent CRNA practice is ridiculous.
 
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DocVapor

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Also, they get credit for "doing" a case if they are merely present in the room and participate in any aspect of the case. I had two SRNAs claim credit for the same CABG when one placed the arterial line, one intubated, and both watched as I did the case.
Wow.

I am an early MS4, and using this rule I am already pretty much done with some of the requirements in Mman's post.

That's just... Terrifying.
 
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BLADEMDA

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The "collaborative model" is semantics for essentially independent CRNA practice. The primary aim of this model is cost-containment with little to no regard for quality care, patient safety, and appropriate oversight of CRNAs by anesthesiologists.

I might concede that there are settings in which it could be appropriate for seasoned CRNAs to work with very limited or no supervision - healthy adults undergoing minor procedures. That is not the situation with this model. It is inappropriate and unsafe to expect a single anesthesiologist to manage 6 to 8 CRNA locations with sick as **** ASA III/IV in complex cases, pedi, and OB.

Now add a weak or locums anesthesiologist + some new grad CRNAs (because the wise, competent clinicians left when the AMC took over), and a few SRNAs serving as staff and you can easily understand the flaws in this model.

I not only "didn't like" that I felt we were not doing the right thing for the patients, I hated it. I hated going to work in fear that I would be assigned a case that I do not have the depth and breadth of training to handle. I hated leaving students from mediocre programs with minimal clinical experience alone because I was needed elsewhere. I hated the expectation that I was obligated to assist other CRNAs and SRNAs when the anesthesiologist was unavailable and there was trouble.

I need to feel good about the care I provide. I also need to protect my assets. I chose to stop working rather than risk an adverse patient outcome and/or a lawsuit.

I do not care about the AANA and their agenda. I do not have the training to work in that kind of model, and no one, NO ONE, can tell me that a CRNA's education is equal to an anesthesiologist's education.



Accurate. I graduated amongst the top in my class from a nationally-known, well-respected program having never placed a central line or PNB. No fiberoptic. Heart rotation observation only. Made neuro and thoracic numbers by doubling up. No infants < one year. This is NOT uncommon, but it is the reason why CRNA and anesthesiologist training cannot be equated. In my opinion, it is also the reason why independent CRNA practice is ridiculous.

Plenty of jobs out there in the ACT model where a good crna can earn $160-170k per year doing an honest days work.
Why quit at this point? Did you hit it big in the market? Sell your Northstar private equity stock?

Independent CRNA practice is a reality in many States so it isn't ridiculous just dangerous. Yet, if a few more people die as a result of solo CRNA practice I expect the AANA and CMS will just sweep it under the rug along with Clinton's e mails.
 

HenryH

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The "collaborative model" is semantics for essentially independent CRNA practice. The primary aim of this model is cost-containment with little to no regard for quality care, patient safety, and appropriate oversight of CRNAs by anesthesiologists.

I might concede that there are settings in which it could be appropriate for seasoned CRNAs to work with very limited or no supervision - healthy adults undergoing minor procedures. That is not the situation with this model. It is inappropriate and unsafe to expect a single anesthesiologist to manage 6 to 8 CRNA locations with sick as **** ASA III/IV in complex cases, pedi, and OB.

Now add a weak or locums anesthesiologist + some new grad CRNAs (because the wise, competent clinicians left when the AMC took over), and a few SRNAs serving as staff and you can easily understand the flaws in this model.

I not only "didn't like" that I felt we were not doing the right thing for the patients, I hated it. I hated going to work in fear that I would be assigned a case that I do not have the depth and breadth of training to handle. I hated leaving students from mediocre programs with minimal clinical experience alone because I was needed elsewhere. I hated the expectation that I was obligated to assist other CRNAs and SRNAs when the anesthesiologist was unavailable and there was trouble.

I need to feel good about the care I provide. I also need to protect my assets. I chose to stop working rather than risk an adverse patient outcome and/or a lawsuit.

I do not care about the AANA and their agenda. I do not have the training to work in that kind of model, and no one, NO ONE, can tell me that a CRNA's education is equal to an anesthesiologist's education.
Thanks for the detailed explanation. There's just one other thing I'm curious about. When you say that the goal of the collaborative model is cost containment, are the cost savings typically realized by the AMC or by the hospital? The reason I ask is because several people I know locally who work in healthcare have mentioned that the local patient payer demographic mix is comprised of up to 85-90% Medicaid/Medicare/indigent patients (I.e., only 10-15% of the patient population here actually has private insurance). So I'm wondering if Northstar is using the collaborative model here because they can simply make more money with in ANY demographic locale, or because that's actually the only supervision model that they can come close to "breaking even" with, given the local payer mix. In other words, could it be that some areas are so poor that the ACT model simply isn't financially sustainable?
 
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BLADEMDA

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Thanks for the detailed explanation. There's just one other thing I'm curious about. When you say that the goal of the collaborative model is cost containment, are the cost savings typically realized by the AMC or by the hospital? The reason I ask is because several people I know locally who work in healthcare have mentioned that the local patient payer demographic mix is comprised by up to 85-90% Medicaid/Medicare/indigent patients (I.e., only 10-15% of the patient population here actually has private insurance). So I'm wondering if Northstar is using the collaborative model here because they can simply make more money with in ANY demographic locale, or because that's actually the only supervision model that they can come close to "breaking even" with, given the local payer mix. In other words, could it be that some areas are so poor that the ACT model simply isn't financially sustainable?
That's a cop out. If the hospital wants to do surgery is the provider a NP or a physician Surgeon? If the hospital wants to do cardiac stents is the provider a NP or a cardiologist? What about the ER? One doesn't dumb down the specialty to an advanced practice nurse make up for lack of funds.

Anyway, the AANA couldn't care less about patient safety and states openly its providers are just as safe and effective as the real thing:

https://www.aana.com/aboutus/Documents/legalissuesnap.pdf
 
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Plenty of jobs out there in the ACT model where a good crna can earn $160-170k per year doing an honest days work.
Why quit at this point? Did you hit it big in the market? Sell your Northstar private equity stock?

Independent CRNA practice is a reality in many States so it isn't ridiculous just dangerous. Yet, if a few more people die as a result of solo CRNA practice I expect the AANA and CMS will just sweep it under the rug along with Clinton's e mails.
Respect your posts that I've read over the years and agree re: good jobs in the ACT model. But I've moved twice for good jobs just to have the practice lost to an AMC. Will not be a third time. Decided that if I were to return to health care it would be as a physician. No shortcuts or midlevels. No political spin from the AANA in exchange for annual dues of $645 (because should you refuse to join, punitive fees are assessed during certification renewal).

No big hits, regrettably.

Anyway, the AANA couldn't care less about patient safety and states openly its providers are just as safe and effective as the real thing:

https://www.aana.com/aboutus/Documents/legalissuesnap.pdf
Accurate. Read this current job ad. Their patient demographic is poor and immigrant.

Group of CRNAs covering trauma center with a full scope of practice, no MD supervision/direction. our ideal candidate, would have experience with TEE, blocks, Lines and want to take care of sick patients. prefer 5 years experience. over $250,000 1099.
 
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Thanks for the detailed explanation. There's just one other thing I'm curious about. When you say that the goal of the collaborative model is cost containment, are the cost savings typically realized by the AMC or by the hospital? The reason I ask is because several people I know locally who work in healthcare have mentioned that the local patient payer demographic mix is comprised of up to 85-90% Medicaid/Medicare/indigent patients (I.e., only 10-15% of the patient population here actually has private insurance). So I'm wondering if Northstar is using the collaborative model here because they can simply make more money with in ANY demographic locale, or because that's actually the only supervision model that they can come close to "breaking even" with, given the local payer mix. In other words, could it be that some areas are so poor that the ACT model simply isn't financially sustainable?
I was never privy to the financials, so any answer I gave would be speculative.

I do know in one instance that there was either a substantial reduction or elimination of the anesthesia subsidy. That is exactly how the contract was stolen.
 

HenryH

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I was never privy to the financials, so any answer I gave would be speculative.

I do know in one instance that there was either a substantial reduction or elimination of the anesthesia subsidy. That is exactly how the contract was stolen.
Whenever I hear about an AMC nabbing the contract at a facility by offering the same/a superior level of service for no subsidy, it makes me wonder -- is it possible for an AMC to profit by implementing 1:4 med. direction and no subsidy, or would an AMC (or any group in general) basically have no choice but to expand beyond 1:4 supervision ratios in order to make money?
 

criticalelement

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Whenever I hear about an AMC nabbing the contract at a facility by offering the same/a superior level of service for no subsidy, it makes me wonder -- is it possible for an AMC to profit by implementing 1:4 med. direction and no subsidy, or would an AMC (or any group in general) basically have no choice but to expand beyond 1:4 supervision ratios in order to make money?
1:4 supervision is dangerous unless you have super stud crnas (unlikely) or 2 of those rooms are no brainers.. cataracts, mac podiatry cases..
 

Mman

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Whenever I hear about an AMC nabbing the contract at a facility by offering the same/a superior level of service for no subsidy, it makes me wonder -- is it possible for an AMC to profit by implementing 1:4 med. direction and no subsidy, or would an AMC (or any group in general) basically have no choice but to expand beyond 1:4 supervision ratios in order to make money?
They can always make money because they pay their MDs and CRNAs/AAs less money and they can collect more on their commercially insured patients. American's newest deal is trying to not pay overtime to CRNAs/AAs by sending them home early if they don't need them on certain days so they don't go over 40 hours in a week.
 

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They can always make money because they pay their MDs and CRNAs/AAs less money and they can collect more on their commercially insured patients. American's newest deal is trying to not pay overtime to CRNAs/AAs by sending them home early if they don't need them on certain days so they don't go over 40 hours in a week.
That works in a slack practice, but in a busy 24/7 practice, someone is going to be getting paid for those non-7-3 hours. It's either OT or paying evening/night staff that may or may not be actually working.
 

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That works in a slack practice, but in a busy 24/7 practice, someone is going to be getting paid for those non-7-3 hours. It's either OT or paying evening/night staff that may or may not be actually working.
they are doing it in some fairly busy practices. You do it by sending people home early that worked late the day before so nobody gets an afternoon break.
 
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Whenever I hear about an AMC nabbing the contract at a facility by offering the same/a superior level of service for no subsidy, it makes me wonder -- is it possible for an AMC to profit by implementing 1:4 med. direction and no subsidy, or would an AMC (or any group in general) basically have no choice but to expand beyond 1:4 supervision ratios in order to make money?
I should think that depends entirely on the payor mix. I have only worked in rural facilities with primarily uninsured or government-insured patients. In my experiences with AMC takeovers, the practice model immediately changed. The models also changed during the contract, ostensibly to address financial losses. I saw 1:6, one anesthesiologist doing cases alongside CRNAs but also serving as a rescuer, one anesthesiologist serving as a Medical Director but CRNAs working independently. More CRNAs, less physicians. Students as staff. Longer hours, more call, less PTO. Questionable methods of calculating time worked.

AMCs are profit-motivated first and foremost.
 
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Wow.

I am an early MS4, and using this rule I am already pretty much done with some of the requirements in Mman's post.

That's just... Terrifying.

Hell, I'm not even in med school yet and I almost meet some of those requirements just through shadowing/research/etc.

And if you include my experience with research animals (mice, pigs, primates, and more), I'm practically a CRNA already!

Scary.
 

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they are doing it in some fairly busy practices. You do it by sending people home early that worked late the day before so nobody gets an afternoon break.
We start the day with nearly 100 anesthetists, and more than 40 will be working OT every day, on top of 8-10 that work a late shift each day. Going home early doesn't happen anywhere near enough to balance the number of OT hours we generate. But the alternative is worse - hiring additional staff to cover those late hours, with the salary and benefit costs that come with each one. It's cheaper to pay OT for the time needed, then boot them out the door as the OR's close for the day.
 

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We start the day with nearly 100 anesthetists, and more than 40 will be working OT every day, on top of 8-10 that work a late shift each day. Going home early doesn't happen anywhere near enough to balance the number of OT hours we generate. But the alternative is worse - hiring additional staff to cover those late hours, with the salary and benefit costs that come with each one. It's cheaper to pay OT for the time needed, then boot them out the door as the OR's close for the day.
100 crnas,, geez,, there must be some locker room.. how does anyone manage such a practice.... it would take a full day just to make the schedulre...
 
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jwk

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100 crnas,, geez,, there must be some locker room.. how does anyone manage such a practice.... it would take a full day just to make the schedulre...
;) oh no, not that many CRNA's by any means. We're about 70:30 AA:CRNA. Our actual total is about 130 anesthetists at the moment, and about 100 of those are working at 7am on any given weekday, spread out over three hospitals and a dozen ASCs. We actually have full-time office people that do the monthly anesthetist and MD schedules, and even then it's computer generated. I used to do it on an Excel spreadsheet until we were up to about 80 people, and then my practice decided that was not a good use of my time (and salary).

It takes about an hour or so to do daily assignments a day ahead of time. We've got that down to an art form.
 

Mman

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We start the day with nearly 100 anesthetists, and more than 40 will be working OT every day, on top of 8-10 that work a late shift each day. Going home early doesn't happen anywhere near enough to balance the number of OT hours we generate. But the alternative is worse - hiring additional staff to cover those late hours, with the salary and benefit costs that come with each one. It's cheaper to pay OT for the time needed, then boot them out the door as the OR's close for the day.
I didn't say they eliminate all OT, but they are really cutting back on it and in practices as big as yours.
 

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Also, they get credit for "doing" a case if they are merely present in the room and participate in any aspect of the case. I had two SRNAs claim credit for the same CABG when one placed the arterial line, one intubated, and both watched as I did the case.
While this may occur, it is not endorsed by the AANA nor the NBCRNA nor the COA. And if there are program directors out there that are turning a blind eye to this occurring, then that should be dealt with. Cases are supposed to be counted if the SRNA does the case from start to finish. No in between. The fact that it (more than likely) is occurring, is a problem. But it is not a nation-wide/program-wide sentiment.
 

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Hell, I'm not even in med school yet and I almost meet some of those requirements just through shadowing/research/etc.

And if you include my experience with research animals (mice, pigs, primates, and more), I'm practically a CRNA already!

Scary.
Sure thing, Spinach. Keep eating the dip.
 

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While this may occur, it is not endorsed by the AANA nor the NBCRNA nor the COA. And if there are program directors out there that are turning a blind eye to this occurring, then that should be dealt with. Cases are supposed to be counted if the SRNA does the case from start to finish. No in between. The fact that it (more than likely) is occurring, is a problem. But it is not a nation-wide/program-wide sentiment.

Disagree here. It is very common in many programs in my State. You have no idea what % of programs tolerate or "turn a blind eye" to this practice and it could be 50% or more of all the programs.
 
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I didn't say they eliminate all OT, but they are really cutting back on it and in practices as big as yours.
Correct.

Or, they circumvent the issue by paying salaries to physicians and CRNAs, citing exemption to pay for hours worked in excess of 40 per the Fair Labor Standard Act's definition of a "professional". This is one way they can still produce a profit in facilities with a poor payor mix.

At one point, our group was averaging 60+ hours per week (excluding call weekends) on base compensation after they changed the coverage to 24/7 in-house call.

Questionable ethics and greed appear to be common characteristics of the AMCs that are picking up these rural contracts. One of Northstar's Chief Medical Officers (whatever that is) went to a honky tonk and found some trouble a few years back. He sued for about $4.5 million dollars, claiming "emotional distress". This is publicly-available information. www.wsmv.com/story/19600270/doctor-files-lawsuit-against-rippys

I should think there are more admirable ways to generate income than getting into a fight at a bar…like, say, actually doing cases.

Money, money, money at the expense of quality patient care and the clinicians who are earning it for them.
 
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jwk

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While this may occur, it is not endorsed by the AANA nor the NBCRNA nor the COA. And if there are program directors out there that are turning a blind eye to this occurring, then that should be dealt with. Cases are supposed to be counted if the SRNA does the case from start to finish. No in between. The fact that it (more than likely) is occurring, is a problem. But it is not a nation-wide/program-wide sentiment.
That's the problem - they don't deal with it. They have no interest in dealing with it. It may not be "endorsed" but it's not prohibited.
 
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While this may occur, it is not endorsed by the AANA nor the NBCRNA nor the COA. And if there are program directors out there that are turning a blind eye to this occurring, then that should be dealt with. Cases are supposed to be counted if the SRNA does the case from start to finish. No in between. The fact that it (more than likely) is occurring, is a problem. But it is not a nation-wide/program-wide sentiment.
What are you? A student?

Please show me the specific language corroborating your assertion that "cases are [only] supposed to be counted if the SRNA does the case from start to finish" in this document:

http://home.coa.us.com/accreditation/Documents/Standards for Accreditation of Nurse Anesthesia Education Programs.pdf

The COA is a multidisciplinary body, separate from the AANA, that evaluates nurse anesthesia programs. The COA also approves new programs. So where do you think the efforts have been focused for the past several years?

Please just stop posting now. You will make us look even worse.
 
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deansrv72

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What are you? A student?

Please show me the specific language corroborating your assertion that "cases are [only] supposed to be counted if the SRNA does the case from start to finish" in this document:

http://home.coa.us.com/accreditation/Documents/Standards for Accreditation of Nurse Anesthesia Education Programs.pdf

The COA is a multidisciplinary body, separate from the AANA, that evaluates nurse anesthesia programs. The COA also approves new programs. So where do you think the efforts have been focused for the past several years?

Please just stop posting now. You will make us look even worse.
Sure, buddy. COA accredits programs. They are the ones that determine if a program is meeting requirements to graduate students. If you recall, NBCRNA is the entity that determines if the student has appropriately met their case/numbers, in order to sit for boards.
Maybe think before you write, or you'll continue to make us look bad.
 

deansrv72

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That's the problem - they don't deal with it. They have no interest in dealing with it. It may not be "endorsed" but it's not prohibited.
I can't speak to why PDs turn their heads, if that's even the case. But if it's knowingly happening, I agree, that's a disservice.
What I do know, is where there's a program within a medical college, let's say, it becomes quite an ordeal to rid of a student. That's just the tip of the iceberg, but I'm sure you get the gist.
 

deansrv72

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Disagree here. It is very common in many programs in my State. You have no idea what % of programs tolerate or "turn a blind eye" to this practice and it could be 50% or more of all the programs.
Well, I disagree. I like to believe I'm more informed than you, about my profession. That being said, just because it's very common in your state (no proof, just your words), it doesn't make it right. And you have no idea what % of programs tolerate this practice, either. Yes, could be more than 50%, but truth is, only the programs themselves truly know.
And for the students to be doing that practice, well, that just speaks volumes as to why they come out fully dependent, and with a less than stellar knowledge bank. But I'm sure I'm saying nothing new here.