CRNA: We are the Answer - WTF????

[AdmiralChz]

No, not outside of academics. It's typically CCM, or ER, or hospitalists that respond to codes where I've worked. If the hospital wants your department to be responsible for that, and they expect you guys to provide a free body at all times to do that, then you should absolutely be getting paid for that.

Our group does 2/3 hospital code coverage, and it factors into our trauma coverage stipend. For the other hospital we cover for like 6 hours when there is only 1 ED doc in house, mostly as a courtesy.

That being said, it’s pretty rare to see that out in the community like you said.

---

Members don't see this ad.

 

[Gern Blansten]

As soon as you used that word I automatically assumed your intelligence level was low and that any answer would not be comprehended.

 

[chocomorsel]

We dont make 500k. Its the total package including benefits, malpractice, retirement, license costs, etc.. I think that number is on par with a salary of 425 which I think is average.

You need one extra doc for float coverage for 40 rooms?!

Yes of course we are resonsible for code coverage outside the OR... isnt that usually how it is?

Code blue, hmm just let me wait until they finish closing and ill run up there between cases..

The numbers I used in my example were reasonable and round..

I haven't heard of the anesthesiologists being responsible for codes outside the OR. How did you agree to that? Where are the hospitalists and intensivists? That honestly seems impractical to me. Airway, ok, but codes, hmm. But I am sure there is plenty of variability.

Yes, one extra doc for float coverage of 40 rooms. I am being generous. As you can see from other posters, they don't have a float person. You pee, poop and eat between cases. And sometimes you don't. Docs don't tend to wine as much as CRNAs about getting three official breaks a day. I hated starving on certain days but I worked in a very money hungry group where surgeons often had two rooms or super short turn overs. I doubt most practices are like that. But I could be wrong.

I have never made 500K, but I ain't mad at you. I wish I did, but I don't know if I would take a job with that kind of money if it meant supervising 4 nurses all day every day. I feel like I run around like a chicken with my head cut off. Just saying that there are docs out there who make less working alone and could make more supervising, but choose not to. And there are places where you can make apparently 500K working alone. To each their own right. Like some other poster suggested, some of your docs could be day docs/mommy track docs who don't do call and therefore make almost CRNA type wages.

Like you said, it's what people are used to. I bet you could slowly phase in more physicians over some years and get rid of problem nurses. Keep the PA/AAs because they seem more amicable. I do agree that plenty of CRNAs are very respectful and just want to work together and go home but there are plenty of bad apples due to the AANA Koolaid.

 

[chocomorsel]

Haha, he don't care. When keeping it real goes wrong!!! I personally love his crass honesty.

 

[AdmiralChz]

Yes, one extra doc for float coverage of 40 rooms. I am being generous. As you can see from other posters, they don't have a float person.

What would you do in case of illness or family emergencies? They happen, and 1 extra person for 40 locations isn’t enough unless you have a pre or post call person you can backfill with.

 

[bronx43]

Haha, he don't care. When keeping it real goes wrong!!! I personally love his crass honesty.

Except it’s idiocy. Online diction doesn’t make someone smart or not.

In fact, anyone who actually thinks so is likely unintelligent himself/herself.

 

[abolt18]

What would you do in case of illness or family emergencies? They happen, and 1 extra person for 40 locations isn’t enough unless you have a pre or post call person you can backfill with.

Not to mention vacation.

 

[Neopolymath]

How common is this scenario: Docs sit most rooms and the board/call doc supervises crnas 3:1. It's an eat what you kill system with a fair way to pick your room for the next day so opportunities to get the $ rooms is available to everyone if they want it. The crnas are legit just there to give lunches and fill in the holes in the schedule. Not a trauma center so after business hours/day cases done, everyone is off the hook but the call doc. Most of the docs do heart coverage as well. When I worked there, they did maybe 1 case a night?

Maybe it's because this place wasn't super crazy busy, but it seemed like a sustainable environment with really happy docs. They got a good lifestyle and control of their cases. When they weren't on call, they could do the joint room with 12 cases or go to day surgery and do 3 hernias and go home at lunch. OB wasn't crazy busy either. These guys probably could have been physician only, but I think they gained a lot of clout with the hospital being able to send an extra body to EP or MRI or whatever when the need came up.

I bring that up because my other experiences have been places that needed coverage in 30+ OR averaging over 100 cases a day, high volume hearts, EP, GI (every patient on the schedule sick as hell), OB, some surgery centers, etc etc. Call was in house and you definitely worked the whole night most nights on. High volume blocks and 10ish minute turnovers. Strong group, but obviously the demand of the system was far different than the first practice environment. How could you manage this without 75+ anesthetists? Why would you want to manage this without some anesthetists? I'm young and brainwashed, but why would I want to pay someone $350k to do the podiatry room? Is using any midlevels at all the line for forsaking your profession?

 

[chocomorsel]

What would you do in case of illness or family emergencies? They happen, and 1 extra person for 40 locations isn’t enough unless you have a pre or post call person you can backfill with.

You answered your own question.

 

[Neopolymath]

You answered your own question.

The general lesson of these posts (not singling you out by any means) is that you just deal. That makes sense. Physicians are like the only people in healthcare that actually know what that means and have the work ethic to do so. No block doc, just deal. 2 people out, run one less room etc. Need to poop, well GI is gonna have a few minute delay. Where are these people working that the hospital and whiny surgeons are ok with this? Is it because they are out West and it's a culture I'm completely ignorant to? Because from what I can tell, half the posts on this forum are people saying that they get no say in anything ever and the surgeon owns their ass blah blah blah and the other posts are people saying that taking more time to do things doesn't matter so they don't need anesthetist extenders. Are the people out West more patient and understand that doing the block in the room might take 5 minutes extra, but it doesn't matter because their candy ass takes forever to do the surgery anyways? If you told people around here that I think they might actually keel over and die.

 

[AdmiralChz]

You answered your own question.

Throw in some vacation and hospital committee meetings (your group better be heavily involved here) it becomes untenable with so few people. And very unpleasant with most pre and post call people working to cover, we’d never be able to recruit for it.

What about trauma, OB, and emergency coverage? Just wait until something finishes and put a room on hold? That’ll make your group popular...

It works for some groups, and hats off to them, but being so lean would be awful and suboptimal for the institution.

 

[AdmiralChz]

No block doc, just deal. 2 people out, run one less room etc.

Exactly!! This sort of thinking is fantasy (sorry, didn’t read your full post at first).

Which surgeon are you going to tell can’t operate today when you close a room? Draw straws? Reimbursement? Popular vote? You start delaying the orthos (already working until 5 PM) so you can get the blocks done and they’ll also kill you.

This will get you in hot water so fast in the C-suite you’ll be replaced quicker than you can say “AMC”

 

[Neopolymath]

Which surgeon are you going to tell can’t operate today when you close a room? Draw straws? Reimbursement? Popular vote?

This will get you in hot water so fast in the C-suite you’ll be replaced quicker than you can say “AMC”

I agree. Surgeons already get pissed when a rotating monthly OR meeting causes a late start on one of their days every 3 months. In the SE (and surely most places?), your group would be DOA for that type of behavior. I'm just a lowly med student with a lot of anesthesia exposure but some of these posts are incongruent with much of what I have experienced or been told. I feel like I am missing something and want to learn!

I think the anesthesiology subforum is the best subforum on SDN. I appreciate everyone's time here.

 

[Twiggidy]

The general lesson of these posts (not singling you out by any means) is that you just deal. That makes sense. Physicians are like the only people in healthcare that actually know what that means and have the work ethic to do so. No block doc, just deal. 2 people out, run one less room etc. Need to poop, well GI is gonna have a few minute delay. Where are these people working that the hospital and whiny surgeons are ok with this? Is it because they are out West and it's a culture I'm completely ignorant to? Because from what I can tell, half the posts on this forum are people saying that they get no say in anything ever and the surgeon owns their ass blah blah blah and the other posts are people saying that taking more time to do things doesn't matter so they don't need anesthetist extenders. Are the people out West more patient and understand that doing the block in the room might take 5 minutes extra, but it doesn't matter because their candy ass takes forever to do the surgery anyways? If you told people around here that I think they might actually keel over and die.

I think it depends on where you are. Let me put it this way, there are certain areas of the country that many a residency graduate would love to practice for whatever reason. Maybe they want to be near the ocean. Maybe the want to be near the mountains. Maybe they want to be somewhere that is only a 6hr flight from Europe. Lots of reasons to classify a place as "desirable". In these "desired" locations, you have to practice a certain way or else, they'll find someone who will and there will certainly be someone out there who's willing to play the game if you aren't.

So while at a hospital in Palo Alto you may have to do some bending over, there's a hospital in say, Alabama where you can't probably flex more muscle. Is that good for the field overall? Probably not, but that's just the way the supply/demand curve of these "desired" locations work. So yes, I may have to keep my mouth shut in certain situations where others would be fine screaming it out.

Not sure if that's what you were wondering or not

 

[deleted162650]

Man I’m glad to live/work in a laid back part of the country where I can work MD only and don’t have to be too scared to pee in between cases. Some of your guys’ professional environment sounds f***ing miserable.

 

[Twiggidy]

Throw in some vacation and hospital committee meetings (your group better be heavily involved here) it becomes untenable with so few people. And very unpleasant with most pre and post call people working to cover, we’d never be able to recruit for it.

What about trauma, OB, and emergency coverage? Just wait until something finishes and put a room on hold? That’ll make your group popular...

It works for some groups, and hats off to them, but being so lean would be awful and suboptimal for the institution.

Yeah. I really depends on the group and that group's mindset. In the "lean" situation someone is going to be unhappy, which is either the surgeons/hospital or the anesthesia group. Some groups just go ahead and take the punishment, and you're right, those groups are hard to recruit, but being so lean (and if busy enough) those groups tend to be lucrative.

 

[nimbus]

Throw in some vacation and hospital committee meetings (your group better be heavily involved here) it becomes untenable with so few people. And very unpleasant with most pre and post call people working to cover, we’d never be able to recruit for it.

What about trauma, OB, and emergency coverage? Just wait until something finishes and put a room on hold? That’ll make your group popular...

It works for some groups, and hats off to them, but being so lean would be awful and suboptimal for the institution.

All of this is done in many places with zero CRNAs. A group can run as lean or as fat as they like using just MD’s.

 

[Twiggidy]

Man I’m glad to live/work in a laid back part of the country where I can work MD only and don’t have to be too scared to pee in between cases. Some of your guys’ professional environment sounds f***ing miserable.

I don't care where I am, the surgeon's are going to wait for me to drop my deuce, which will include time to scroll through The 'Gram.

 

[Neopolymath]

All of this is done in many places with zero CRNAs. You can run as lean or as fat as you like using just MD’s.

Are you eat what you kill? Who is getting paid less in this scenario? Partner-employee wage gap lower etc? Economically, seems like SOMEONE has to make less money which is fine because at a certain point it isn't about money.

 

[nimbus]

Are you eat what you kill? Who is getting paid less in this scenario? Partner-employee wage gap lower etc? Economically, seems like SOMEONE has to make less money which is fine because at a certain point it isn't about money.

Yes eat what you kill so sometimes we have a day off and make nothing and other days we work 18 hours and make a lot. No wage gap.

 

[Consigliere]

Haha, he don't care. When keeping it real goes wrong!!! I personally love his crass honesty.

Chocomorsel is correct....getting called a jerk (and worse) is like shooting bullets at Superman....that bullshiggity bounces right off me.

 

[deleted162650]

Are you eat what you kill? Who is getting paid less in this scenario? Partner-employee wage gap lower etc? Economically, seems like SOMEONE has to make less money which is fine because at a certain point it isn't about money.

The pay gap is not as great as you might think between MD only and ACT. You have to run high ratio all the time for it to be more profitable. Then keep in mind it takes more than one CRNA to replace 1 MD since they are shift workers and you gotta pay salary and benefits to all of them.

Most MD only practices are some variation on the eat-what-you-kill theme. If you have a blended unit of 40$ and turn 12K units/year (pretty average workload) that’s $480K and no CRNA BS to deal with. If the model didn’t work it wouldn’t be the predominant model in 1/3 of the country.

 

[deleted162650]

As soon as you used that word I automatically assumed your intelligence level was low and that any answer would not be comprehended.

Aren’t you from Philly? Pot meet kettle.

 

[Gern Blansten]

Chocomorsel is correct....getting called a jerk (and worse) is like shooting bullets at Superman....that bullshiggity bounces right off me.

As soon as you used that word, I assumed that your intelligence level was low...

 

[chocomorsel]

Exactly!! This sort of thinking is fantasy (sorry, didn’t read your full post at first).

Which surgeon are you going to tell can’t operate today when you close a room? Draw straws? Reimbursement? Popular vote? You start delaying the orthos (already working until 5 PM) so you can get the blocks done and they’ll also kill you.

This will get you in hot water so fast in the C-suite you’ll be replaced quicker than you can say “AMC”

Problem is, you’ve already exceeded expectations, kissed enough ass, taken enough beatings for free that now you probably can’t go back.

Like who’s running hospital codes as part of their contracts without a stipend?

Y'all screwed yourselves or your predecessors did.

Not saying MD only doesn’t have its issues and that we don’t try to move fast, but if the surgeons want these extra things like blocks, they know that it’s gonna rack on a few minutes. Otherwise you can do ortho without blocking patients. It has been done for decades. If the anesthesia group is the one pushing for blocks, then it’s all you to figure out efficiency if the surgeons want to whine about times.

When on call the surgeons with the highest acuity get priority. Otherwise they hash it out. Although when I was out west there was a lot more catering to surgeons after hours. Because of lack of exclusive contracts.

Docs just don’t call in enough for the post call person to be screwed often. When that happens, people get fired because we all do care about keeping our contracts and making money.

I think the ideal situation would be to do own cases with an extra person available or a place where you mostly do own cases and supervise on your call day or infrequently. These situations with 100% supervision are weird and IMO unnecessary.

 

[Mman]

Not saying MD only doesn’t have its issues and that we don’t try to move fast, but if the surgeons want these extra things like blocks, they know that it’s gonna rack on a few minutes. Otherwise you can do ortho without blocking patients. It has been done for decades. If the anesthesia group is the one pushing for blocks, then it’s all you to figure out efficiency if the surgeons want to whine about times.

I have a hard time arguing that PNBs for major ortho cases are considered "extra". It's basically standard of care.

 

[chocomorsel]

I have a hard time arguing that PNBs for major ortho cases are considered "extra". It's basically standard of care.

Well, then the surgeons need to be a little patient.
It’s “basically”standard of care. But is it? It’s all relative.

 

[Southpaw]

there's no perfect model. SDN trends toward MD only because it's considered the holy grail. The only reason it's considered this is because of the AANA. In reality working with CRNAs is fine, pleasant even most of the time. Personally I think it'd be nice to work in a hybrid model where you supervise on some days and do your own cases on others. The reality of anesthesia is that it's awful boring sometimes and it's simply nice to be out of the room. On other days it's nice to be in the OR chatting up the nurses, techs, and surgeons. The other reality, of life in general, is that people live either near residency or their family. They accept the model of anesthesia care in that locale and move on with life.

 

[Twiggidy]

there's no perfect model. SDN trends toward MD only because it's considered the holy grail. The only reason it's considered this is because of the AANA. In reality working with CRNAs is fine, pleasant even most of the time. Personally I think it'd be nice to work in a hybrid model where you supervise on some days and do your own cases on others. The reality of anesthesia is that it's awful boring sometimes and it's simply nice to be out of the room. On other days it's nice to be in the OR chatting up the nurses, techs, and surgeons. The other reality, of life in general, is that people live either near residency or their family. They accept the model of anesthesia care in that locale and move on with life.

This is so correct. This may sound like ammunition for the nurses but in reality about 70% of the cases I do I don't need to be parked in the room reading Reddit. On the other hand some of my vascular disasters and the heart patients I believe, personally, my expertise and skill is a benefit to those patients. I also don't need to be running to rooms to give top offs on OB or holding hands during C/S. That's just my honest opinion.....although some would argue that's what I'm being paid for.

 

[Mman]

Well, then the surgeons need to be a little patient.
It’s “basically”standard of care. But is it? It’s all relative.

either your hospital can do things as efficiently as possible or patients will ultimately end up elsewhere. It's the nature of the beast in healthcare. Continual improvement or someone else will do the job.

 

[chocomorsel]

either your hospital can do things as efficiently as possible or patients will ultimately end up elsewhere. It's the nature of the beast in healthcare. Continual improvement or someone else will do the job.

Yeah. Maybe. But when all the hospitals in the region are doing similar things.. ain’t gonna be much difference in another facility.
Only hospital I saw suffering was the Prime hospital because they were gouging people. Not necessarily because they were or were not efficient.

 

[ryanjmy]

This is so correct. This may sound like ammunition for the nurses but in reality about 70% of the cases I do I don't need to be parked in the room reading Reddit. On the other hand some of my vascular disasters and the heart patients I believe, personally, my expertise and skill is a benefit to those patients. I also don't need to be running to rooms to give top offs on OB or holding hands during C/S. That's just my honest opinion.....although some would argue that's what I'm being paid for.

I agree with this. The notion that we’ve got to keep the nurses down to protect the specialty is the wrong mentality. They’ve improved over the years and will continue to do so whether we teach them or not. The key is staying several steps ahead of them which isn’t hard to do.

I’ve probably worked with a couple hundred CRNAs by now. I’ve yet to meet one that I wouldn’t trust doing a cataract. I’ve also never met one that could manage a difficult cv case by themselves.

 

[Mman]

Well, then the surgeons need to be a little patient.
It’s “basically”standard of care. But is it? It’s all relative.

is there any hospital of any decent size in the country that is not doing peripheral nerve blocks for major joint replacements or things like rotator cuffs? I mean I can believe there are probably a handful of tiny podunk places that just put a tube in people and send them home with a bunch of percocet, but that would be laughed at in most of the country at this point.

 

[chocomorsel]

is there any hospital of any decent size in the country that is not doing peripheral nerve blocks for major joint replacements or things like rotator cuffs? I mean I can believe there are probably a handful of tiny podunk places that just put a tube in people and send them home with a bunch of percocet, but that would be laughed at in most of the country at this point.

There are. And they aren’t podunk.
Or what’s your definition of podunk?
There are old school surgeons out there who don’t like nor want blocks.
Can’t change their minds.
And there are hospitals where everyone is independent and the culture is whatever the surgeons want.
The ones who do, in an MD only independent practice learn to have a little patience. Not constant delaying cases patience but patience for an extra few minutes cuz it’s best for their patients.
Sometimes when driving from hospital to hospital, there are inevitable delays.
It’s cultural depending on the region.

 

[Urzuz]

I agree with this. The notion that we’ve got to keep the nurses down to protect the specialty is the wrong mentality. They’ve improved over the years and will continue to do so whether we teach them or not. The key is staying several steps ahead of them which isn’t hard to do.

I’ve probably worked with a couple hundred CRNAs by now. I’ve yet to meet one that I wouldn’t trust doing a cataract. I’ve also never met one that could manage a difficult cv case by themselves.

This is so correct. This may sound like ammunition for the nurses but in reality about 70% of the cases I do I don't need to be parked in the room reading Reddit. On the other hand some of my vascular disasters and the heart patients I believe, personally, my expertise and skill is a benefit to those patients. I also don't need to be running to rooms to give top offs on OB or holding hands during C/S. That's just my honest opinion.....although some would argue that's what I'm being paid for.

Am I in $%&#ing crazy town? I can't believe what I am reading.

Go back and re-read what started this entire thread. I don't know how much clearer it needs to be made from the AANA leadership and some (most?) of their members -- they believe anesthesiologists are superfluous and an added burden on the healthcare. This thinking that "I don't need to be part of x y z which is a mundane part of anesthesiology" is what got us into this $%&#ing mess to begin with. It is an all-or-none situation. You either believe there should be an anesthesiologist involved in EVERY aspect of anesthesia care or NO aspect of anesthesia care. There is no picking and choosing what parts of a patient's care you want to be involved in. It has been proven time and time again that if you agree to relinquish the "boring" or "easy" anesthetics to the nurses, the other side will grow more and more confident and continue encroaching on your territory, even that territory that you feel is "protected." Don't be a lazy SOB and take an active role in the care of all patients.

I can somewhat wrap my head around how previous posters were discussing the financial viability of MD-only practice in certain parts of the country, but here you guys are actively saying that the nurses can effectively and safely perform certain anesthetics with little to no involvement from us. The AANA slaps you in the face and you turn the other cheek. What a $%&#ing joke.

 

[hypnosMD]

This is so correct. This may sound like ammunition for the nurses but in reality about 70% of the cases I do I don't need to be parked in the room reading Reddit. On the other hand some of my vascular disasters and the heart patients I believe, personally, my expertise and skill is a benefit to those patients. I also don't need to be running to rooms to give top offs on OB or holding hands during C/S. That's just my honest opinion.....although some would argue that's what I'm being paid for.

My objection here is that the “easy” 70% to which you refer is retrospective. Predicting the disastrous 30% is not always by the book, nor is it always the complex cases/patients. The clinical acumen to discern is the result of a medical education.

 

[Mman]

There are. And they aren’t podunk.
Or what’s your definition of podunk?
There are old school surgeons out there who don’t like nor want blocks.
Can’t change their minds.
And there are hospitals where everyone is independent and the culture is whatever the surgeons want.
The ones who do, in an MD only independent practice learn to have a little patience. Not constant delaying cases patience but patience for an extra few minutes cuz it’s best for their patients.
Sometimes when driving from hospital to hospital, there are inevitable delays.
It’s cultural depending on the region.

LOL

Just point them out so we can take over their business for them. I literally can't believe that. It's like telling me that people are doing cardiac cases with mega doses of morphine.

 

[chocomorsel]

LOL

Just point them out so we can take over their business for them. I literally can't believe that. It's like telling me that people are doing cardiac cases with mega doses of morphine.

They don’t want you because you love working with CRNAs and think they ACT model is superior. Surgeons out west are used to and prefer docs.

So...it won’t work for you cuz you won’t have anyone to make money off.

 

[Twiggidy]

Am I in $%&#ing crazy town? I can't believe what I am reading.

Go back and re-read what started this entire thread. I don't know how much clearer it needs to be made from the AANA leadership and some (most?) of their members -- they believe anesthesiologists are superfluous and an added burden on the healthcare. This thinking that "I don't need to be part of x y z which is a mundane part of anesthesiology" is what got us into this $%&#ing mess to begin with. It is an all-or-none situation. You either believe there should be an anesthesiologist involved in EVERY aspect of anesthesia care or NO aspect of anesthesia care. There is no picking and choosing what parts of a patient's care you want to be involved in. It has been proven time and time again that if you agree to relinquish the "boring" or "easy" anesthetics to the nurses, the other side will grow more and more confident and continue encroaching on your territory, even that territory that you feel is "protected." Don't be a lazy SOB and take an active role in the care of all patients.

I can somewhat wrap my head around how previous posters were discussing the financial viability of MD-only practice in certain parts of the country, but here you guys are actively admitting that the nurses can effectively and safely perform certain anesthetics with little to no involvement from us. The AANA slaps you in the face and you turn the other cheek. What a $%&#ing joke.

Yeah. Let me jump up out of my chair during this hysteroscopy and SHOW MY WORTH. It's not all-or-none and that's a ridiculous notion to even come to bring to the table. I don't even really work with CRNAs but I can almost guarantee that one that knows their head from their butt is a valuable member of the team. But that's the real problem. None of us view this as a team game. They (some) want more money and to not be micromanage and we want them to kneel before Zodd. Meanwhile if we all just checked our egos on both side and actual DID take focus on the patient like you say, this field could be efficient and lucrative for everyone. Do I want them screwing up a PNB or screwing up invasive lines or managing the sickest patients? No, that's what OUR training was for. Are they useful in a cataract, D/C, ureteroscopy, or hell even some lap choles and hip pinnings? They sure are. People just need to learn to work together and all sorts of caish can be made. And don't fool yourself. Most people did this for the money. If you really wanted to "help people" you'd be a surgeon or an IM doc

 

[Twiggidy]

My objection here is that the “easy” 70% to which you refer is retrospective. Predicting the disastrous 30% is not always by the book, nor is it always the complex cases/patients. The clinical acumen to discern is the result of a medical education.

There's truth here. There's always to rough gyn, sloppy ortho, or out of touch gen surgeon that will make the "easy" and complete disaster.

 

[ryanjmy]

Am I in $%&#ing crazy town? I can't believe what I am reading.

Go back and re-read what started this entire thread. I don't know how much clearer it needs to be made from the AANA leadership and some (most?) of their members -- they believe anesthesiologists are superfluous and an added burden on the healthcare. This thinking that "I don't need to be part of x y z which is a mundane part of anesthesiology" is what got us into this $%&#ing mess to begin with. It is an all-or-none situation. You either believe there should be an anesthesiologist involved in EVERY aspect of anesthesia care or NO aspect of anesthesia care. There is no picking and choosing what parts of a patient's care you want to be involved in. It has been proven time and time again that if you agree to relinquish the "boring" or "easy" anesthetics to the nurses, the other side will grow more and more confident and continue encroaching on your territory, even that territory that you feel is "protected." Don't be a lazy SOB and take an active role in the care of all patients.

I can somewhat wrap my head around how previous posters were discussing the financial viability of MD-only practice in certain parts of the country, but here you guys are actively saying that the nurses can effectively and safely perform certain anesthetics with little to no involvement from us. The AANA slaps you in the face and you turn the other cheek. What a $%&#ing joke.

I couldn’t care less what the nursing organization leaders’ thinks of me. In fact my group recently got rid of one of thier board members for attitude problems. It’s been my experience that the crnas that have the biggest egos are the worst clinically. It’s really a matter of poor self awareness.

And twiggy addresses the all or nothing thing. None of us are advocating solo crna practice. My point is if you feel threaten by CRNAs you probably need to up your game some.

 

[MoMoGesiologist]

Am I in $%&#ing crazy town? I can't believe what I am reading.

Go back and re-read what started this entire thread. I don't know how much clearer it needs to be made from the AANA leadership and some (most?) of their members -- they believe anesthesiologists are superfluous and an added burden on the healthcare. This thinking that "I don't need to be part of x y z which is a mundane part of anesthesiology" is what got us into this $%&#ing mess to begin with. It is an all-or-none situation. You either believe there should be an anesthesiologist involved in EVERY aspect of anesthesia care or NO aspect of anesthesia care. There is no picking and choosing what parts of a patient's care you want to be involved in. It has been proven time and time again that if you agree to relinquish the "boring" or "easy" anesthetics to the nurses, the other side will grow more and more confident and continue encroaching on your territory, even that territory that you feel is "protected." Don't be a lazy SOB and take an active role in the care of all patients.

I can somewhat wrap my head around how previous posters were discussing the financial viability of MD-only practice in certain parts of the country, but here you guys are actively saying that the nurses can effectively and safely perform certain anesthetics with little to no involvement from us. The AANA slaps you in the face and you turn the other cheek. What a $%&#ing joke.

Such a dramatic response... you really think an MD needs to be personally delivering anesthesia for every ASA1 lap chole or sitting every c-section in the country? My time and education is better focused on sick patients and difficult cases, or multitasking multiple cases. If you feel you need to be involved for every easy case, that may be more a reflection on your discomfort in the OR, not the rest of us being lazy.

No need to sit on a stool and personally chart vitals for every single patient. You know who’s really good for things like that? Nurses! Every other specialty uses nurses to do grunt work. Why shouldn’t anesthesia employ nurses to do simple straightforward things.

 

[Urzuz]

Yeah. Let me jump up out of my chair during this hysteroscopy and SHOW MY WORTH. It's not all-or-none and that's a ridiculous notion to even come to bring to the table. I don't even really work with CRNAs but I can almost guarantee that one that knows their head from their butt is a valuable member of the team. But that's the real problem. None of us view this as a team game. They (some) want more money and to not be micromanage and we want them to kneel before Zodd. Meanwhile if we all just checked our egos on both side and actual DID take focus on the patient like you say, this field could be efficient and lucrative for everyone. Do I want them screwing up a PNB or screwing up invasive lines or managing the sickest patients? No, that's what OUR training was for. Are they useful in a cataract, D/C, ureteroscopy, or hell even some lap choles and hip pinnings? They sure are. People just need to learn to work together and all sorts of caish can be made. And don't fool yourself. Most people did this for the money. If you really wanted to "help people" you'd be a surgeon or an IM doc

I couldn’t care less what the nursing organization leaders’ thinks of me. In fact my group recently got rid of one of thier board members for attitude problems. It’s been my experience that the crnas that have the biggest egos are the worst clinically. It’s really a matter of poor self awareness.

And twiggy addresses the all or nothing thing. None of us are advocating solo crna practice. My point is if you feel threaten by CRNAs you probably need to up your game some.

Such a dramatic response... you really think an MD needs to be personally delivering anesthesia for every ASA1 lap chole or sitting every c-section in the country? My time and education is better focused on sick patients and difficult cases, or multitasking multiple cases. If you feel you need to be involved for every easy case, that may be more a reflection on your discomfort in the OR, not the rest of us being lazy.

No need to sit on a stool and personally chart vitals for every single patient. You know who’s really good for things like that? Nurses! Every other specialty uses nurses to do grunt work. Why shouldn’t anesthesia employ nurses to do simple straightforward things.

Yup, you guys got me, me believing an anesthesiologist should be involved in every anesthetic is a reflection of my shortcomings as an anesthesiologist and not my professional integrity, or me wanting to draw a line in the sand that makes anesthesia a MEDICAL specialty.

Keep allowing your nurses to play active roles in your "care teams" (just typing that phrase makes me cringe) while you guys keep your heads in the sand.

 

[Mman]

They don’t want you because you love working with CRNAs and think they ACT model is superior. Surgeons out west are used to and prefer docs.

So...it won’t work for you cuz you won’t have anyone to make money off.

I don't think either physician only or ACT is superior in terms of patient outcome. I believe in the data that shows they are equivalent. I also believe if people provide inferior and inefficient care that their hospital will get rid of them no matter what model they are using. Anybody doing total shoulders and rotator cuffs and total knees without peripheral nerve blocks should not be practicing medicine in this day and age. I shudder to think what else they have not kept up with.

 

[Dejavu]

is there any hospital of any decent size in the country that is not doing peripheral nerve blocks for major joint replacements or things like rotator cuffs? I mean I can believe there are probably a handful of tiny podunk places that just put a tube in people and send them home with a bunch of percocet, but that would be laughed at in most of the country at this point.

We went through a decade + of every knee/hip/shoulder got a PNB. Then Experel happened. Now about half or more of our surgeons do their own “block”.

This after several studies to prove efficacy and patient satisfaction.

One could debate whether Rochester, Minnesota is a “podunk” town, but the Clinic that lives there definitely isn’t.

 

[AdmiralChz]

One could debate whether Rochester, Minnesota is a “podunk” town, but the Clinic that lives there definitely isn’t.

Mayo has a very advanced and progressive regional program that is quite busy with blocks for ortho gen surg thoracic gyn peds...

What are you taking about?

 

[Mman]

We went through a decade + of every knee/hip/shoulder got a PNB. Then Experel happened. Now about half or more of our surgeons do their own “block”.

This after several studies to prove efficacy and patient satisfaction.

One could debate whether Rochester, Minnesota is a “podunk” town, but the Clinic that lives there definitely isn’t.

If surgeons can provide equivalent analgesia, then that's cool by me. We had some orthos that went to their meetings and claimed it was the same. We collected 72 hours of data on every joint patient for 18 months with some surgeons doing their exparel and us doing PNBs on the rest. Now our surgeons have totally abandoned their exparel in the joint because it just doesn't work as well.

 

[chocomorsel]

I don't think any model is superior in terms of patient outcome. I believe in the data and the science. I also believe if people provide inferior and inefficient care that their hospital will get rid of them. Anybody doing total shoulders and rotator cuffs and total knees without peripheral nerve blocks should not be practicing medicine in this day and age. I shudder to think what else they have not kept up with.

All these bellow are your quotes. So I am a little confused. But we already know how you really feel so no need to try and sidestep.


"It actually did show superiority in the best study done to date from North Carolina CMS data in the 1970s and 1980s. Lowest mortality rate of physician only, CRNA only, or ACT model was the ACT model. I'm too lazy to dig up the link for you.
If one doc in a room doing his own thing is "shooting birdies" in your mind, how come none of the biggest and best hospitals in the country are doing it that way? I mean it seems absurd that MGH or Stanford or Hopkins or wherever else you want to name doesn't have a board certified anesthesiologist in the room for the duration of every case if it were so much better for the patient.
It just isn't. While you wish it true, that doesn't make it true. The ASA fully supports the ACT model and it's safety and efficacy is proven beyond doubt."


"I work in ACT model and would take a pay cut to work in ACT model compared to MD only. I think it's just better. I realize not all agree, but I have no desire to sit on the stool in the room for the duration of the case. I'd rather spend all my time coming up with plans and actually doing things rather than just sitting around. Some days I'll do 15 or 20 peripheral nerve blocks. Other days I'll put in 4 or 5 central lines. Other days I'll get to do several difficult intubations. I like doing procedures and I do a TON more supervising multiple rooms compared to if I was just stuck in a single room all day.
We employ our own CRNAs/AAs and I think that makes all the difference."


" There was a large retrospective study from North Carolina comparing (I believe) 30 day surgical mortality rates with type of anesthesia care model. ACT fared quite well. It actually came in slightly better than MD only, but that wasn't statistically significant. CRNA not supervised by anesthesiologist was the worst as I recall.

So yes, with millions of patients cared for it is proven to be safe. And yes, I'd let any of my loved ones be cared for by our group in our ACT model for any type of surgery. We do it all. Obviously nobody is supervising 3 other rooms when doing a pedi heart. That would be stupid. Our supervision ratio is adjusted to the acuity of the patients."

 

[Consigliere]

Aren’t you from Philly? Pot meet kettle.

Indeed I am. If you were standing in front of me right now it would be a "fist meet face" scenario.

 

[Mman]

All these bellow are your quotes. So I am a little confused. But we already know how you really feel so no need to try and sidestep.

My quotes show why I believe (and studies support) an ACT model is perfectly safe, I am unsure why you are "confused" about that. I have never argued that physician only care is less safe, I just believe it is undoubtedly less efficient. I fully support docs that are happy working in that model to do so. I would not personally enjoy doing so.