ProwlerturnGas

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I will leave anesthesia before I ever supervise again. VA job was the worst and I’ll never go back to that model again.
 

Eagles6389

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I’ve been following this thread for a while and figured I’d throw out what I saw as most disturbing. I’m an incoming PGY-1 who chose anesthesiology, but nearly didn’t after my first exposure to the field at a private practice hospital close to home in the NE region.

The private practice hospital ran 3:1 to 4:1 supervision and each day I was put with a CRNA (since the MD/DO was busy signing charts for pre-op, supervising rooms, etc). Whenever there was a regional block to be done, a spinal/epidural, or basically any procedure, the Anesthesiologist would completely defer to the CRNA. I even remember one of the Anesthesiologists saying “oh, ______ procedure? I haven’t done one in over three years, go get X CRNA to come and do it.” For the new CRNA grads, the anesthesiologists helped teach them anything they wanted and would encourage them to take the tough cases so they could get better.

And I also understand the argument that any employee can be trained to do a procedure, but teaching them still isn’t helping us in any way. It’s just another thing that CRNAs will use for leverage to say that they are equivalent to us. One of the more experienced CRNAs said to me “it shouldn’t be the title (MD/DO vs CRNA) that defines who is more qualified, it should be who is the best overall in administering anesthesia.” And I can see why she thought this considering most of the anesthesiologists supervising her had skill and knowledge atrophy.

So to me, the biggest issue isn’t CRNAs in general, it’s the anesthesiologists who have become lazy and have skill atrophy to the point where they are letting CRNAs do everything under the sun. It’s the anesthesiologists treating CRNAs as if they are Physician residents, teaching them not only complex procedures but also how to think through complex cases.
 

jwk

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These mid level providers are running wild at Duke, Vandy, Emory etc...
Unless something has changed, Emory hospitals do NOT have the DNP students in their ORs. The Emory anesthesia department, part of the medical school, did not support the DNP CRNA program which is part of the nursing school. Emory University itself just sees the tuition $$$. There are a lot of anesthesia groups in Georgia that want absolutely nothing to do with Emory's DNP program.
 

Osminog

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Is CRNA upcreep really posing a threat to the anesthesiology job market? According to Medscape surveys, it seems that anesthesiologist salaries been modestly increasing the past few years.

Also, when it comes to patient safety, are there any large-scale, reliable studies comparing CRNA and anesthesiologist patient outcomes? The only widely cited one seems to be the 2010 article from Health Affairs, but it was funded by the AANA.
 

IMGASMD

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I’ve been following this thread for a while and figured I’d throw out what I saw as most disturbing. I’m an incoming PGY-1 who chose anesthesiology, but nearly didn’t after my first exposure to the field at a private practice hospital close to home in the NE region.

The private practice hospital ran 3:1 to 4:1 supervision and each day I was put with a CRNA (since the MD/DO was busy signing charts for pre-op, supervising rooms, etc). Whenever there was a regional block to be done, a spinal/epidural, or basically any procedure, the Anesthesiologist would completely defer to the CRNA. I even remember one of the Anesthesiologists saying “oh, ______ procedure? I haven’t done one in over three years, go get X CRNA to come and do it.” For the new CRNA grads, the anesthesiologists helped teach them anything they wanted and would encourage them to take the tough cases so they could get better.

And I also understand the argument that any employee can be trained to do a procedure, but teaching them still isn’t helping us in any way. It’s just another thing that CRNAs will use for leverage to say that they are equivalent to us. One of the more experienced CRNAs said to me “it shouldn’t be the title (MD/DO vs CRNA) that defines who is more qualified, it should be who is the best overall in administering anesthesia.” And I can see why she thought this considering most of the anesthesiologists supervising her had skill and knowledge atrophy.

So to me, the biggest issue isn’t CRNAs in general, it’s the anesthesiologists who have become lazy and have skill atrophy to the point where they are letting CRNAs do everything under the sun. It’s the anesthesiologists treating CRNAs as if they are Physician residents, teaching them not only complex procedures but also how to think through complex cases.
As a recent grad who is studying for oral boards I will try to point you to a different way of looking at this.
You’re a physician first and foremost. It’s much more than just the intraop management. It’s even much more than the procedures. (I know this is what pays the bill.) It’s actual diseases and pathophys that you’ll have to master. It’s also the responsibility and “own it” mentality that you will learn during training. It’s that responsibility piece that will separate you out from a CRNA.

Intubation, procedure or even “simple” intraop complications can all be taught, I’d venture to say I can teach CRNA top three differentials for intraop problems.

Why don’t you want to drop BP for critical AS? Can you give spinal to an AS patient, due to other co-existing medical problems? Most CRNA probably will have hard time to work that out themselves. And stand-by their choices.

The nurses training are fundamentally different than a doctor’s training, whether they like to admit or not. They all beat their chest they can do it, until the **** hits the fan. Or the second thing they tried didn’t work. You, the physician, need to know plan c, d, e, f, g..... also can you see a crna have a frank or intelligent conversation with the procedurlist?
I do all my egd under mac, why can’t you doctor nurse?


Good luck.
 
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Plead the Fifth

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Nobody wants to live in podunk rural America with a 13% private payer mix. And hospital employs the CRNAs, not our group. Solo MD anesthesia occurs but is rare unfortunately, I wish I was able to do it more often.

AANA pisses me off to no end but CRNAs I work with are good people and take direction well. Solo is just not an option for some places.
 

Gasper

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I’ve been following this thread for a while and figured I’d throw out what I saw as most disturbing. I’m an incoming PGY-1 who chose anesthesiology, but nearly didn’t after my first exposure to the field at a private practice hospital close to home in the NE region.

The private practice hospital ran 3:1 to 4:1 supervision and each day I was put with a CRNA (since the MD/DO was busy signing charts for pre-op, supervising rooms, etc). Whenever there was a regional block to be done, a spinal/epidural, or basically any procedure, the Anesthesiologist would completely defer to the CRNA. I even remember one of the Anesthesiologists saying “oh, ______ procedure? I haven’t done one in over three years, go get X CRNA to come and do it.” For the new CRNA grads, the anesthesiologists helped teach them anything they wanted and would encourage them to take the tough cases so they could get better.

And I also understand the argument that any employee can be trained to do a procedure, but teaching them still isn’t helping us in any way. It’s just another thing that CRNAs will use for leverage to say that they are equivalent to us. One of the more experienced CRNAs said to me “it shouldn’t be the title (MD/DO vs CRNA) that defines who is more qualified, it should be who is the best overall in administering anesthesia.” And I can see why she thought this considering most of the anesthesiologists supervising her had skill and knowledge atrophy.

So to me, the biggest issue isn’t CRNAs in general, it’s the anesthesiologists who have become lazy and have skill atrophy to the point where they are letting CRNAs do everything under the sun. It’s the anesthesiologists treating CRNAs as if they are Physician residents, teaching them not only complex procedures but also how to think through complex cases.
a lot of people in academics seem to enjoy teaching CRNA, to make them more competent so they can just sign charts and disappear. They know their academic jobs are secure so it doesn't matter if the CRNA go to PP to compete for someone else's jobs . It's someone else's problem.
 

dannyboy1

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As a recent grad who is studying for oral boards I will try to point you to a different way of looking at this.
You’re a physician first and foremost. It’s much more than just the intraop management. It’s even much more than the procedures. (I know this is what pays the bill.) It’s actual diseases and pathophys that you’ll have to master. It’s also the responsibility and “own it” mentality that you will learn during training. It’s that responsibility piece that will separate you out from a CRNA.

Intubation, procedure or even “simple” intraop complications can all be taught, I’d venture to say I can teach CRNA top three differentials for intraop problems.

Why don’t you want to drop BP for critical AS? Can you give spinal to an AS patient, due to other co-existing medical problems? Most CRNA probably will have hard time to work that out themselves. And stand-by their choices.

The nurses training are fundamentally different than a doctor’s training, whether they like to admit or not. They all beat their chest they can do it, until the **** hits the fan. Or the second thing they tried didn’t work. You, the physician, need to know plan c, d, e, f, g..... also can you see a crna have a frank or intelligent conversation with the procedurlist?
I do all my egd under mac, why can’t you doctor nurse?


Good luck.
Unfortunately nobody cares about the thought process or the training. Especially with AMC’s who just want the job done at the lowest price possible. As long as the complications are kept to an acceptable level they just want cases cranked out. They would have the janitor deliver anesthesia if they could ......
 
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Consigliere

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Unfortunately nobody cares about the thought process or the training. Especially with AMC’s who just want the job done at the lowest price possible. As long as the complications are kept to an acceptable level they just want cases cranked out. They would have the janitor deliver anesthesia if they could ......
:whistle:"Oh, Danny boy, the pipes, the pipes are calling..." and you're 100% correct.
 

AdmiralChz

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Unfortunately nobody cares about the thought process or the training. Especially with AMC’s who just want the job done at the lowest price possible. As long as the complications are kept to an acceptable level they just want cases cranked out. They would have the janitor deliver anesthesia if they could ......
To be fair, this could be said of any and all services at a given hospital - anesthesia, emergency med, surgery, radiology, nursing, engineering, cleaning staff.........

Reasonable outcomes at a low cost? Sign us up says the C-Suite.
 

2Fast2Des

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To be fair, this could be said of any and all services at a given hospital - anesthesia, emergency med, surgery, radiology, nursing, engineering, cleaning staff.........

Reasonable outcomes at a low cost? Sign us up says the C-Suite.
Ortho can be done by any skilled handyman. I mean they'll operate on anything with a pulse
 

Hoya11

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I remember one of the omfs residents back in med school tell me, choose a residency based on what you will enjoy and to accept that most of any specialty will be bread and butter, and if you're okay with that you won't be disappointed if you don't actually see zebras all the time. He was right, yes they're boring but it's part of the variety we do. Can't claim we're awesome at everything but that we're too good for some. Except when I catch my CRNA turn a simple local asa1 case into why the F are the sats in the 60s and extreme jaw thrust being done and only caught it because I happened to walk in at the right time because I was never notified. So yeah I'll take an MD all day
Thats not the bread and butter I want.

If I had to do those cases routinely I would not do anesthesia.

My bread and butter needs to be more engaging, and it is.

Every day I'm going Alines, Blocks, Intubations myself. Giving blood/pressors in challenging cases. Those things are my routine.

Yes its better to have an MD in the room, Yes they are higher quality. But for these easy cases I've listed, that are not the bread and butter but the low hanging fruit, where there is no airway involved and healthy people under MAC, is it really realistic? You would really be OK sitting on the stool in an eye room giving 2 of versed all day, earning less than supervising, because you don't trust a CRNA to do an eye case? For rapid, easy cases, I do believe supervision makes more sense.
 

2Fast2Des

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Thats not the bread and butter I want.

If I had to do those cases routinely I would not do anesthesia.

My bread and butter needs to be more engaging, and it is.

Every day I'm going Alines, Blocks, Intubations myself. Giving blood/pressors in challenging cases. Those things are my routine.

Yes its better to have an MD in the room, Yes they are higher quality. But for these easy cases I've listed, that are not the bread and butter but the low hanging fruit, where there is no airway involved and healthy people under MAC, is it really realistic? You would really be OK sitting on the stool in an eye room giving 2 of versed all day, earning less than supervising, because you don't trust a CRNA to do an eye case? For rapid, easy cases, I do believe supervision makes more sense.
Not all day everyday, I would go nutso as well. But usually different kind of cases every day, if one of those days ends up being the lone eyeball or the GI day then it's part of the gig in a community setting.
 
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OTCAwesome

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Not all day everyday, I would go nutso as well. But usually different kind of cases every day, if one of those days ends up being the lone eyeball or the GI day then it's part of the gig in a community setting.

I concur, it's nice to have an mellow post call eyeball or GI day after taking care of train wreck cardiac and trauma cases all week. Also doubles as free time to plan your next vacation.
 

pgg

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I've never had a mellow GI day. It's always 15 or 20 obese patients with lousy airways and fast turnover and a bunch of charting and a room in the basement that smells like vomit and poo. Give me a wreck in the heart room, at least I can sit down a while when we're on bypass. :)
 

dannyboy1

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I've never had a mellow GI day. It's always 15 or 20 obese patients with lousy airways and fast turnover and a bunch of charting and a room in the basement that smells like vomit and poo. Give me a wreck in the heart room, at least I can sit down a while when we're on bypass. :)
Agreed. GI is not easy. Patients are often sick, fat, with a stomach that is not quite empty. An easy day is anything with an ETT and an asa 1 or 2 patient
 

chocomorsel

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Thats not the bread and butter I want.

If I had to do those cases routinely I would not do anesthesia.

My bread and butter needs to be more engaging, and it is.

Every day I'm going Alines, Blocks, Intubations myself. Giving blood/pressors in challenging cases. Those things are my routine.

Yes its better to have an MD in the room, Yes they are higher quality. But for these easy cases I've listed, that are not the bread and butter but the low hanging fruit, where there is no airway involved and healthy people under MAC, is it really realistic? You would really be OK sitting on the stool in an eye room giving 2 of versed all day, earning less than supervising, because you don't trust a CRNA to do an eye case? For rapid, easy cases, I do believe supervision makes more sense.
Yes. Because one, money ain’t everything. And those eye rooms make good money BTW.

Two...I don’t want to be responsible for other peoples mistakes. As in a CRNAs.

Three, patients deserve the most highly qualified person even in the damn eye room.

Four, plenty of us like sitting our own cases. Are surgeons giving their low hanging fruit like appys and choles to the NPs and PAs?

Lastly, the greed in this field is what has led us to where we are today. Training, teaching and then fighting our replacements. All in the name of “more money”. How much money is enough?
 
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Mman

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Ya... physician ACT mode.

Big difference.
you are either insisting there is a board certified anesthesiologist in the room for the entirety of every case or you are not, because I doubt anybody walks into the hospital insisting they have a CA1 sit alone in their case for hours on end by themselves.

Besides, soon enough the nurses will be doing the surgery by themselves also.

The Royal College of Surgeons describes it as
  • Once the surgeon is satisfied the SCP works safely and competently within their role, they can arrange for proximal supervision (where the surgeon is not in theatre but their location is within the hospital, and can be easily contactable)


I am totally in favor of anesthesiologists doing their own cases. I personally feel it is a waste of your ability and education to only do one case at a time, but if people want to practice that way they should be free to. I enjoy the challenge and complexity of doing more during my day and love our ACT model. I understand there are poor examples of ACT out there, but that would seem to be location and individual specific. I would be hard pressed to find locations having better risk adjusted outcomes than we achieve in a massive level 1 trauma center with extremely fat and unhealthy patients.
 
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SaltyDog

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I think it’s a little disingenuous to refer to training programs as “ACT” practices. I mean, every training institution in every single medical specialty involves board certified physicians supervising non-board certified PHYSICIANS at varying levels. It’s not like you would say a surgical residency is practicing in an SCT model.

The argument is for there to be a PHYSICIAN in the room for the entirety of every case.
 

beepbloop

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These mid level providers are running wild at Duke, Vandy, Emory etc...
I hate to go against the grain here, but I have a fair amount of experience with one of the named programs in multiple arenas and by no stretch of the imagination are the mid levels running wild.
 

vector2

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I hate to go against the grain here, but I have a fair amount of experience with one of the named programs in multiple arenas and by no stretch of the imagination are the mid levels running wild.
Thanks for this extremely specific and valiant defense of whichever institution you’re talking about...?
 
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Mman

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I think it’s a little disingenuous to refer to training programs as “ACT” practices. I mean, every training institution in every single medical specialty involves board certified physicians supervising non-board certified PHYSICIANS at varying levels. It’s not like you would say a surgical residency is practicing in an SCT model.

The argument is for there to be a PHYSICIAN in the room for the entirety of every case.
I think it's disingenuous to refer to residencies as anything other than ACT models. A first day resident left alone in the room might be a physician, but they are neither board eligible or board certified. I have plenty of experienced AAs and CRNAs that I'd much prefer taking care of myself or my family than any junior resident at any program in the country.
 
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Southpaw

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a junior resident is much more likely to call their attending than either a junior or experienced CRNA. This is the fault of the AANA. Now certainly, a junior physician resident will need a bit more hand holding in the OR, but calling when questions arise is a valuable skill that many CRNAs like to forget. Again, blame rests squarely on the shoulders of the AANA. Unfortunately it is the patient who suffers.
 
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a junior resident is much more likely to call their attending than either a junior or experienced CRNA. This is the fault of the AANA. Now certainly, a junior physician resident will need a bit more hand holding in the OR, but calling when questions arise is a valuable skill that many CRNAs like to forget. Again, blame rests squarely on the shoulders of the AANA. Unfortunately it is the patient who suffers.
The end-game for the CRNAS has not been well thought out. What do they want? Physician status?
They want the money? If they get the money, there would be no need for them. It would just open up the door to an alternative cheaper variety. The Anesthesiolgist Assistant who they cannot supervise. THey will price themselves out of the market. Technology can and will displace them faster than us.
 
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sevoflurane

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you are either insisting there is a board certified anesthesiologist in the room for the entirety of every case or you are not, because I doubt anybody walks into the hospital insisting they have a CA1 sit alone in their case for hours on end by themselves.

Besides, soon enough the nurses will be doing the surgery by themselves also.

The Royal College of Surgeons describes it as
  • Once the surgeon is satisfied the SCP works safely and competently within their role, they can arrange for proximal supervision (where the surgeon is not in theatre but their location is within the hospital, and can be easily contactable)


I am totally in favor of anesthesiologists doing their own cases. I personally feel it is a waste of your ability and education to only do one case at a time, but if people want to practice that way they should be free to. I enjoy the challenge and complexity of doing more during my day and love our ACT model. I understand there are poor examples of ACT out there, but that would seem to be location and individual specific. I would be hard pressed to find locations having better risk adjusted outcomes than we achieve in a massive level 1 trauma center with extremely fat and unhealthy patients.
Listen, we’ve been down this road before. You do as you like. I m not feeding any part of the parasitism that is devouring our field. Glad you have your little island, but the bigger picture is what is important to me.

I sleep good at night knowing I am not part of that problem.

Wasted talent? Ya think as you wish.

I’m moving. All the time. One patient at a time. Complex cases.

Monday I have 3 TAVRs with tte/tee followed by 2 mitral clips (echo heavy).

I wouldn’t want to step out of that room for a second and I sure as hell wouldn’t hand over an echo probe, or a cvl, or a block. That is called training the enemy or shooting yourself in the foot.

Trust me... seconds do matter when you are busy in other rooms.

To ea. their own.
 

Southpaw

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It sure is nice to see the MD only crowd stand on a soapbox stating they aren’t part of the problem. Def not - they live in a nice little cocoon by choice. Meanwhile, from my purview the entire east coast is heavily reliant on a supervision model. You cardiac/regional/peds gurus - could you point me to all of the MD only hospitals located on the east coast? Could you point me to 5? 10? But then I guess the answer is for all anesthesiologists living on the East Coast to uproot and head west. Sure, sounds real viable.
 

T-burglar

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I don’t train CRNAs and I don’t work with them. Most of the rooms I work in simply can’t be done by CRNAs because a consultant level TEE or TTE is required.
 
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SaltyDog

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It sure is nice to see the MD only crowd stand on a soapbox stating they aren’t part of the problem. Def not - they live in a nice little cocoon by choice. Meanwhile, from my purview the entire east coast is heavily reliant on a supervision model. You cardiac/regional/peds gurus - could you point me to all of the MD only hospitals located on the east coast? Could you point me to 5? 10? But then I guess the answer is for all anesthesiologists living on the East Coast to uproot and head west. Sure, sounds real viable.
Don’t be silly. The solution is straight forward. Stop hiring new CRNAs and hire MDs instead. It’s a gradual wean, and it’d be very doable.
 

nimbus

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Last I checked, the West also has the lowest or second lowest average compensation for anesthesiologists. We’re not just standing on a soapbox but also putting our money where our mouth is. Of course we could put more $$$ in our (or somebody’s) pockets by directing or supervising. Thankfully there’s zero will to do so.
 

Southpaw

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Don’t be silly. The solution is straight forward. Stop hiring new CRNAs and hire MDs instead. It’s a gradual wean, and it’d be very doable.

Easily said. Most anesthesiologists that I know, especially in PP and especially more seniors ones, aren’t particularly open to change. It takes everyone on the same page for such a move, and while I’d love for it to happen I won’t hold my breath. Most of us have accepted the ACT however unpalatable it may be. Seriously though, aside from a handful of places in VA does anyone know of ANY hospitals on the east coast that are MD only or even MD mostly?
 
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Kinda Unrelated but the other day I was on a dating app and there was this girl who is a PA student who wrote in her bio "Studying to become Assistant Physician" lol.

Looks like US healthcare is heading to a bright future.
 
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Southpaw

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Last I checked, the West also has the lowest or second lowest average compensation for anesthesiologists. We’re not just standing on a soapbox but also putting our money where our mouth is. Of course we could put more $$$ in our (or somebody’s) pockets by directing or supervising. Thankfully there’s zero will to do so.
I don’t see it that way. I see it as you all doing it the same way you’ve always done. No different than ACT practices. And if you were to move to supervision half of your docs would lose their job. Let’s not pretend all those West coast jobs are perfect. If they were I wouldn’t get so many recruiter emails about them. But I’m very happy you can make it work MD only. It’s a great model.
 
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VA Hopeful Dr

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Don’t be silly. The solution is straight forward. Stop hiring new CRNAs and hire MDs instead. It’s a gradual wean, and it’d be very doable.
I'm FP so my knowledge is very limited...

Are there enough anesthesiologists to cover all the ORs/endoscopy suites in the country?

I know in primary care there just aren't enough doctors to cover the need for primary care, not by a long shot. Is y'all's work force in better shape than ours?
 

Hoya11

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Don’t be silly. The solution is straight forward. Stop hiring new CRNAs and hire MDs instead. It’s a gradual wean, and it’d be very doable.
as long as your willing to double your overhead its no problem...

I would love to do this but my practice would collapse due to the economic forces in the area..
 

nimbus

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I don’t see it that way. I see it as you all doing it the same way you’ve always done. No different than ACT practices. And if you were to move to supervision half of your docs would lose their job. Let’s not pretend all those West coast jobs are perfect. If they were I wouldn’t get so many recruiter emails about them. But I’m very happy you can make it work MD only. It’s a great model.
I agree and see some truth to that. The ACT model has been talked about around here from time to time but the talk is squashed pretty quickly. I think it would take an AMC to impose that model on an MD only practice. Change in either direction is difficult and unwelcome.
 
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IMGASMD

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MD only is absurd
Not sure if you’re serious or being sarcastic....
If there are jobs where i am for md only. I am welling to take a pay cut just so I don’t have to worry/on the hook for my nurses fuuk-ups.
 

Southpaw

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I'm FP so my knowledge is very limited...

Are there enough anesthesiologists to cover all the ORs/endoscopy suites in the country?

I know in primary care there just aren't enough doctors to cover the need for primary care, not by a long shot. Is y'all's work force in better shape than ours?
No, not enough of us. Not even close.
 
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Mman

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I wouldn’t want to step out of that room for a second and I sure as hell wouldn’t hand over an echo probe, or a cvl, or a block. That is called training the enemy or shooting yourself in the foot.
Our physicians do 100% of the TEEs, CVLs, blocks, etc.

And no, our physicians aren't wandering out of the room while they are deploying the valve in a TAVR. There are other docs around to cover anything else needed.
 
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GravelRider

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Easily said. Most anesthesiologists that I know, especially in PP and especially more seniors ones, aren’t particularly open to change. It takes everyone on the same page for such a move, and while I’d love for it to happen I won’t hold my breath. Most of us have accepted the ACT however unpalatable it may be. Seriously though, aside from a handful of places in VA does anyone know of ANY hospitals on the east coast that are MD only or even MD mostly?
There’s a whole bunch of MD only practices in the Philadelphia to Boston corridor...probably more than 10. There’s even more MD-mostly. Whether they are “fair, democratic” private practices is another story. There’s a lot of used car salesman practices looking to augment their income with cheap MD employees, but if you want to do your own cases, the northeast is generally a good place to look.
 
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