Denver VA surgeries cancelled due to anesthesiologist shortage

[cchoukal]

An incentive based system will ALWAYS outperform a salary based system. As an active duty physician the military creates metrics that are not applicable to the civillian standard. As someone who has seen both systems their is an apathy in military medicine as it pertains to pace and patient care. People stop working hard when they know they cannot be fired. In any civilian OR people can be fired in the military its more complicated. I imagine the VA to similar to military medicine.

I think that depends on what you mean by "outperform." If you mean "do more cases," definitely. But you get what you incentivize. What percentage of the cases you do in PP, where the surgeon has a boat payment to make, are actually, 100% necessary? Ever get pushed to do a case on a less-safe patient in a less-safe manner at a less-safe time of day?

With salaries and performance pay, with performance linked to quality standards, maybe you get better performance on those standards. And we have productivity targets, too, but we're not paid based on that.

I don't think the VA is perfect, by any stretch, but I do think there are things the VA does that work well and align with my ethics, and, under most circumstances, they stay out of the way of providing good care (with the exception of giving is all the staff we'd like).

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[chocomorsel]

Maybe in psych care. I don’t presume to know.

I live and work in a military town. 20-30 percent of our medical staff is ex-military and probably 50% of our OR staff (scrub techs and nurses) are as well. They are not going to the local VA when they need surgery.

When I was a resident, the surgeons at the VA were definitely not cream of the crop. The cardiac surgeon in particular was notoriously bad. We are talking 3-4hr pump runs for a cabg. He eventually ended up returning to his home country.

You are complaining about 3 to 4 hour pump runs? That's crazy fast for some academic surgeons. Where I trained a CABG took 8 to 12 hours with 6 to 10 hour pump runs. At the VA they at least new how to do off pump cases and that cut down the time significantly.

 

[WisNeuro]

Outperform who? And what long term outcome measures? I’m skeptical.

There are plenty of studies, including some larger RAND studies that are publicly available if you'd like numbers over chyrons.

 

[narcusprince]

I think that depends on what you mean by "outperform." If you mean "do more cases," definitely. But you get what you incentivize. What percentage of the cases you do in PP, where the surgeon has a boat payment to make, are actually, 100% necessary? Ever get pushed to do a case on a less-safe patient in a less-safe manner at a less-safe time of day?

With salaries and performance pay, with performance linked to quality standards, maybe you get better performance on those standards. And we have productivity targets, too, but we're not paid based on that.

I don't think the VA is perfect, by any stretch, but I do think there are things the VA does that work well and align with my ethics, and, under most circumstances, they stay out of the way of providing good care (with the exception of giving is all the staff we'd like).

I have been pushed to do an elective case with a less safe surgeon at a less safe hour. The creme rises to the top give me a private practice surgeon who has the best outcomes. Very likely you will not see this at a VA hospital or military hospital. Those who can run for greener pastures.

 

[nimbus]

You are complaining about 3 to 4 hour pump runs? That's crazy fast for some academic surgeons. Where I trained a CABG took 8 to 12 hours with 6 to 10 hour pump runs. At the VA they at least new how to do off pump cases and that cut down the time significantly.

All I can say is that those staff surgeons have no business teaching other surgeons.

 

[sheeed]

You are complaining about 3 to 4 hour pump runs? That's crazy fast for some academic surgeons. Where I trained a CABG took 8 to 12 hours with 6 to 10 hour pump runs. At the VA they at least new how to do off pump cases and that cut down the time significantly.

8 hours? is that door to door time or skin to skin? jesus thats long

 

[Iso4ane]

I wonder if the shortage is due to lack of personnel or lazy personnel, and whether that is currently due to physician forces or CRNA forces. Cause the CRNA response would be great if the current shortage was due to lack of CRNAs

 

[Psai]

I wonder if the shortage is due to lack of personnel or lazy personnel, and whether that is currently due to physician forces or CRNA forces. Cause the CRNA response would be great if the current shortage was due to lack of CRNAs

I doubt it has anything to do with physicians or nurse anesthetists. If you've ever worked at any VA, it is invariably a nursing issue. It's not even just laziness, it's sheer incompetence and a complete disdain for efficiency.

 

[WholeLottaGame7]

I doubt it has anything to do with physicians or nurse anesthetists. If you've ever worked at any VA, it is invariably a nursing issue. It's not even just laziness, it's sheer incompetence and a complete disdain for efficiency.

Time for my favorite VA joke (might have heard it on here first):

What's the difference between a bullet and a VA nurse?






A bullet can be fired, it can draw blood, and it only kills once.

 

[Twiggidy]

8 hours? is that door to door time or skin to skin? jesus thats long

not completely unusually for an academic setting. i remember valves used to take...

 

[sheeed]

not completely unusually for an academic setting. i remember valves used to take...

That would make me want to shoot myself. Guess we have pretty good surgeons at my cardiac program.

 

[caligas]

American Society of Anesthesiologists - Colorado Society of Anesthesiologists Takes Action to Help Veterans Receive Timely Care

 

[caligas]

 

[MakoMD]

Im going to save you a trillion more. Close all military hospitals and facilities and provide the same care congress gets . Increase the reserve component place all military providers in civilian hospitals. Make sure all people involved in patient care have licenses and board certification. Increase the medical service corps to function as liasons between the physicans and military.

Agree with all, except the increasing the MSC part. LOL - they’re the worst. Like the assistant nurse administrator to the education and training quality committee. What would you say you do here?


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[Noyac]

You are complaining about 3 to 4 hour pump runs? That's crazy fast for some academic surgeons. Where I trained a CABG took 8 to 12 hours with 6 to 10 hour pump runs. At the VA they at least new how to do off pump cases and that cut down the time significantly.

Some of you may know that Choco and I trained at the same place but at different times. Hell, probably different decades.

Choco,I believe I did one of the first few off-pump cases at the VA. THEY WERE FUN!!! They were also instrumental in getting me my first job. Not many grads were coming out of training with many off-pump hearts. My new job was doing most of their cases that way. And damn, they were smooth.

But it seems like something changed drastically at our program. We only did one VA heart a day but we were usually done shortly after lunch as I recall. Too late to start another VA case though.

How long were the pedi hearts? I remember those being fairly quick, maybe a couple hours of pump run.

 

[chocomorsel]

Some of you may know that Choco and I trained at the same place but at different times. Hell, probably different decades.

Choco,I believe I did one of the first few off-pump cases at the VA. THEY WERE FUN!!! They were also instrumental in getting me my first job. Not many grads were coming out of training with many off-pump hearts. My new job was doing most of their cases that way. And damn, they were smooth.

But it seems like something changed drastically at our program. We only did one VA heart a day but we were usually done shortly after lunch as I recall. Too late to start another VA case though.

How long were the pedi hearts? I remember those being fairly quick, maybe a couple hours of pump run.

There were no pedi hearts when I was there. We were getting farmed out to Houston and then San Diego for extra hearts since our program was weak in that regard.
However during my last few months they brought in a surgeon and anesthesiologist from Miami to revamp the CV program and start pedi hearts.
The VA CT rotation was like you remember. Much more efficient than the University.

 

[chocomorsel]

8 hours? is that door to door time or skin to skin? jesus thats long

Either, depending on how many vessels. The surgeons were all slow. Even the locums who defiantly said she could "crash onto Bypass in 30min" on this super obese lady with a saddle embolus that was already dead. Well, it took more than an hour to get on bypass and we couldn't come off pump I don't know how many hours later. Surprise, surprise, she was already dead. Ended up on ECMO and officially dead two days later. Horrible night to be on call.

 

[AdmiralChz]

8 hours? is that door to door time or skin to skin? jesus thats long

Absolutely! 4 vessels, better pack a dinner because it is a guaranteed 10+ hour marathon.

To be fair (or not fair?), we'd routinely be ready to go on bypass but had to wait for 1-2 or more hours so the PA could finish the Endovein harvest. We (including the surgeon) called it Endo-Pain.

Here in fellowship we've been out with 4 vessels before lunch, and mostly extubated before my colleagues back in residency were done with bypass. The majority of surgeons are probably somewhere between the two extremes.

 

[C4C]

I'm no economist, but how on earth is possible that we are generating national headlines about a shortage of anesthesiologists and yet salaries continue to decline and regulations (MOCA, individual state licenses, lack of reciprocity, length of time to obtain hospital credentials, increasing required limits on malpractice premiums...) continue to increase?

Shouldn't our totally worthless ASA get its **** together and stand up for the profession? Are they not aware that the nurses are going to use this as a reason to gain more ground in their march to eliminate anesthesiologists, while simultaneously painting physicians as overpaid? What's that? They are too busy rolling out the uber-worthless FASA to care? Sounds about right.

 

[nimbus]

I'm no economist, but how on earth is possible that we are generating national headlines about a shortage of anesthesiologists and yet salaries continue to decline and regulations (MOCA, individual state licenses, lack of reciprocity, length of time to obtain hospital credentials, increasing required limits on malpractice premiums...) continue to increase?

Shouldn't our totally worthless ASA get its **** together and stand up for the profession? Are they not aware that the nurses are going to use this as a reason to gain more ground in their march to eliminate anesthesiologists, while simultaneously painting physicians as overpaid? What's that? They are too busy rolling out the uber-worthless FASA to care? Sounds about right.

There’s no shortage.

 

[IlDestriero]

Either, depending on how many vessels. The surgeons were all slow. Even the locums who defiantly said she could "crash onto Bypass in 30min" on this super obese lady with a saddle embolus that was already dead. Well, it took more than an hour to get on bypass and we couldn't come off pump I don't know how many hours later. Surprise, surprise, she was already dead. Ended up on ECMO and officially dead two days later. Horrible night to be on call.

If the patient is doing so poorly, and it takes 30-60 min to “crash” onto bypass, why did they even bother? Those brain cells don’t regenerate. Crash onto ecmo maybe?
Sounds like a bad night!


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Il Destriero

 

[Twiggidy]

I'm no economist, but how on earth is possible that we are generating national headlines about a shortage of anesthesiologists and yet salaries continue to decline and regulations (MOCA, individual state licenses, lack of reciprocity, length of time to obtain hospital credentials, increasing required limits on malpractice premiums...) continue to increase?

Shouldn't our totally worthless ASA get its **** together and stand up for the profession? Are they not aware that the nurses are going to use this as a reason to gain more ground in their march to eliminate anesthesiologists, while simultaneously painting physicians as overpaid? What's that? They are too busy rolling out the uber-worthless FASA to care? Sounds about right.

It's not a shortage of anesthesiologists overall. This facility (and maybe others) have a shortage because my best guess would be the salary doesn't match the workload, especially if you're talking about a place like Denver, CO.

It's Denver. it's the Portland of Colorado, or maybe Portland is the Denver of Oregon, regardless, if you have a facility in that place that's having a hard time getting anesthesiologists to work their, that means they aren't paying, at least not enough to make it worth it.

 

[sheeed]

Either, depending on how many vessels. The surgeons were all slow. Even the locums who defiantly said she could "crash onto Bypass in 30min" on this super obese lady with a saddle embolus that was already dead. Well, it took more than an hour to get on bypass and we couldn't come off pump I don't know how many hours later. Surprise, surprise, she was already dead. Ended up on ECMO and officially dead two days later. Horrible night to be on call.

Some of our CT guys must be good then. Can do CABG x3 and a valve in 7 hours.

 

[chocomorsel]

If the patient is doing so poorly, and it takes 30-60 min to “crash” onto bypass, why did they even bother? Those brain cells don’t regenerate. Crash onto ecmo maybe?
Sounds like a bad night!


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Il Destriero

Trust me. I was a senior and tried to tell the attending not to do the case as it was futile. She had already coded twice and we were coding her on the way to the OR. She was on 3 or so pressors. But alas, my attending had no backbone, and went ahead with what the surgeon was telling the family even though she distant agree with it. Surgeon was telling them yes, there was a chance she could make it. I of course told them otherwise. But they don't listen to the anesthesiologists. Had I been an attending, we would not have gone back.
I was up all night, pissed that we were flogging this patient. I ended up calling the chair of surgery at 0630 in the morning to put an end to the madness. No one gave a **** and we just kept going.
Mind you, she weighed like 400lbs and was average height.
And we wonder why healthcare is so crazy expensive in this country.
When I was in Houston, we were routinely taking dead patients on ECMO to and from the OR. I am sure they still do it.

 

[Crabbygas]

I remember during residency transporting a post CABG patient on ECMO to the ICU. As we are pushing the bed down the hall the med student says, "Isn't it amazing that we can take a patient this sick and transport them to the ICU?" The Surgeons response was, "This is nothing we do it all the time." Yeah we did it all the time. Hence The reason the one actual CT fellowship trained guy there refused to do hearts..

 

[Noyac]

Trust me. I was a senior and tried to tell the attending not to do the case as it was futile. She had already coded twice and we were coding her on the way to the OR. She was on 3 or so pressors. But alas, my attending had no backbone, and went ahead with what the surgeon was telling the family even though she distant agree with it. Surgeon was telling them yes, there was a chance she could make it. I of course told them otherwise. But they don't listen to the anesthesiologists. Had I been an attending, we would not have gone back.
I was up all night, pissed that we were flogging this patient. I ended up calling the chair of surgery at 0630 in the morning to put an end to the madness. No one gave a **** and we just kept going.
Mind you, she weighed like 400lbs and was average height.
And we wonder why healthcare is so crazy expensive in this country.
When I was in Houston, we were routinely taking dead patients on ECMO to and from the OR. I am sure they still do it.

Sounds like a good teaching case to me.

 

[chocomorsel]

Sounds like a good teaching case to me.

Total waste of time, resources and manpower.