Exit strategy

[pgg]

Perhaps I should have been more careful in my posting. I'll avoid posts at 3am in the future. The quotes were supposed to reference the "team" in which the MD micromanages everything and treats the CRNAs like a glorified staff nurse who can intubate and turn dials. I would honestly be happy in an ACT setting if i was treated right.

Here's the thing though, CVRN, there are quite a few CRNAs out there who really DO need to be micromanaged, and every single one of them resents the micromanagement. Because they don't think they need the help and they just want to be treated right. They don't know what they don't know.

And here you are, still an SRNA not even done with training yet, and you're already convinced that you won't need to be micromanaged. Are you starting to catch the edges of the big picture now?

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[WholeLottaGame7]

I believe a model where CRNAs and MDs do their own cases independently with MD consultation available as needed is probably in the future.

Just curious as to what advantages this model would have. Consulting an MD would both cost money and imply that you need help with patient care; both areas in which CRNAs currently claim to have an advantage.

 

[IlDestriero]

Just curious as to what advantages this model would have. Consulting an MD would both cost money and imply that you need help with patient care; both areas in which CRNAs currently claim to have an advantage.

Covering 3 or 4 rooms is fireman enough for most anesthesiologists. Taking on the liability for disasters, "consulting" independent CRNAs would be a real disaster. Who wants that job, and who would pay for that. You can't bill for it if you're independent. Now when I see something that "could be managed better" I make recommendations that are followed through on. When I was in the Navy and an "independent" CRNA was given a patient that they really should not have been given in the first place and "not optimally managing" the patient we had to send some of them home early or out for some "admin" or PT time to properly manage the situation.
A few were really freaking scary with shockingly poor clinical judgement and planning and they couldn't take any criticism at all. Those same few would actively ignore any suggestions and become passive aggressive superstars. When they presented at M&M for their near misses, etc. it was a sad joke. They wouldn't even make the effort to research better management strategies WHEN THEY KNEW THAT THEIR CASES WERE BEING PRESENTED. Some don't know what they don't know, and they don't even want to know to become better. And that was in the big Navy referral center where they were expected to practice at a higher standard. (Though I wouldn't really call it truly independent.)
Now, faced with the above situation, we'd just tell them to find another job.

 

[Spinach Dip]

I've posted this before, so I'll c/p it here...


What we need to do is ALLOW crnas to practice independently.

Also, allow them (or their employing hospital) to be sued for malpractice when the spit (inevitably) hits the fan.

It may take a couple years (and wrongful-death lawsuits), but eventually things will work out.

 

[Spinach Dip]

BTW, let me say that I know there are good CRNAs, just like there are bad MDs. Heck, in my recent past I have been under the care of both.

The problem I see is in the mindset. Most CRNAs (in my experience) seem to be of the opinion that they are just as good as doctors, and thus don't need to learn anything else. On the other hand, most doctors are open-minded about learning about new treatment options/techniques and refining their skills.

In short, give me the one who knows there is always more to learn, not the one who thinks they already know everything.

JMHO.

 

[deleted126335]

CVRN: As a student CRNA you have undoubtedly had CRNA preceptors whose style you did not care for. There are undoubtedly some CRNAs that you silently groan when you see your name next to theirs on the days OR schedule. I suspect that some of them are highly competent but simply their supervision style conflicts with yours. The same is undoubtedly true of anesthesiologists. Very few of us are trained on how to be an effective educator and supervisor. Some of us are better at it than others. Some of us are more anal than others and micro manage out of habit. It is nature not out of maliciousness. But some of us micromanage some CRNAs consciously and deliberately. You can thank the professional organization that you pay your dues to for the latter.

 

[countingdays]

I've worked with a range of crnas. Most have been good to work with and happy to have someone to turn to as needed. You can tell the new grads tend to believe the militant view to some degree or other, but over time and after you've helped them out several times, they tend to settle down and enjoy the ACT practice. I've worked with crnas on the far right of the curve, and they still have questions sometimes.
Even the very good crnas will call for help sometimes and they should. The worst case is when they should call you but don't. We should have positive enough relationships that bitterness and jealousy don't get in the way of patient safety. AANA propaganda 'studies' and anti-physician sentiment in nursing schools are a problem, but things are usually much better in the real world.

 

[Consigliere]

...treats the CRNAs like a glorified staff nurse who can intubate and turn dials..

That's what I have done, do, and will do until I retire because that is the surest way to ensure optimal patient outcomes.

 

[deleted171991]

The same is undoubtedly true of anesthesiologists. Very few of us are trained on how to be an effective educator and supervisor.

Excuse me, but my role is not to educate nurses, techs etc. If they want education, they should go to (medical) school. They do not need to know my chain of thinking, beyond the minimum that allows them to fulfill my orders/instructions properly. (Sic volo!) They are neither my student nor my boss.

That's exactly why we are in this hole: we have been giving away our knowledge and craft to CRNAs, nurses etc. for decades. And still it didn't change much, except that now they got an attitude to go with the emmentaler thinking. They don't appreciate all that valuable, free teaching.

...treats the CRNAs like a glorified staff nurse who can intubate and turn dials...

Most CRNAs are well-educated automata, full of knee-jerk type knowledge and (re)actions. The anesthesiologist has to discover what version of firmware they are running, and what bugs are still active (if s/he has the time, patience and masochism...).

 

[wjs010]

SRNA here. While the management of the case below sounds superb it doesn't take a physician to make this diagnosis. You even mentioned you have studied this case scenario a million times but so have CRNAs and probably AAs I would imagine. You actually had the technology and a CT surgeon immediately available to save the patient which is awesome but this is basic anesthesia knowledge. So when I hear things like "the surgeon doesnt want to have be telling the CRNA what to do when an emergency arises" I just scratch my head a bit. Having rotated through a few solo CRNA rural clinical sites I can tell you that this would never happen. Its the exact same dynamic as is seen at the larger centers. A "supervising" surgeon is not somehow blessed with more anesthesia knowledge because they work with CRNAs.

I dont plan on debating anyone on here as this is a physicians forum and I am happy to lurk and learn. I acknowledge that physician training is "better" on average than CRNA training and personally feel that certain requirements for CRNA training need to be elevated. I believe CRNAs and anesthesiologists abilities as providers are two bell curves which overlap to some degree and I hope that the solo CRNAs are falling onto the far right of the curve the majority of the time but we'll never know. Just throwing that caveat in there to hopefully ward off those who think Im just a militant SRNA trolling. Im really not. But some of the stuff posted about midlevels as if they all just follow a protocol and dont critically think is just ridiculous. Happy holidays everyone

I promise this is not a rhetorical question, but why didn't you just go to med school? Anesthesiologists know way the hell more and there is no arguing that, so why didn't you want to be a part of that?

 

[deleted171991]

The less one actually knows, the more one thinks one knows. That's why children have an opinion about everything.

 

[wjs010]

Again I ask to all CRNA and srna, why don't you just go to med school? Why wouldn't you want to be a part of the group that are experts in the field, instead of being disliked by pretty much all anesthesiologists for possibly cheapening and lessening the quality of the field? NOT rhetorical- I really really want to see what you have to say. If you are proud of being a CRNA, let's see what you have to say.

 

[CVRN]

Again I ask to all CRNA and srna, why don't you just go to med school? Why wouldn't you want to be a part of the group that are experts in the field, instead of being disliked by pretty much all anesthesiologists for possibly cheapening and lessening the quality of the field? NOT rhetorical- I really really want to see what you have to say. If you are proud of being a CRNA, let's see what you have to say.

Maybe you didn't notice the original theme of this thread but many Anesthesiologists here are recommending against future residents going into anesthesia. On the contrary I have never met a CRNA that doesn't love their job. I'm not sure where you get the idea that almost all anesthesiologists dislike CRNAs either. Your entire post is rather ridiculous honestly. What about being a CRNA would be bad really?? There are plenty of teachers, factory workers, nurses, police officers and countless other people in other professions that would love to start out at 150K per year as a new grad. I am extremely blessed to be a part of this profession and have the ability to take care of my family and live a very comfortable life. All of this and I haven't even mentioned what I like about the actual job itself. So can you see how stupid your entire premise is? There is so much nonsense in your post I wasn't even sure where to start but I think Im just going to leave it alone as I dont see any reasonable discussion to be had here. Happy holidays everyone!

 

[wjs010]

Maybe you didn't notice the original theme of this thread but many Anesthesiologists here are recommending against future residents going into anesthesia. On the contrary I have never met a CRNA that doesn't love their job. I'm not sure where you get the idea that almost all anesthesiologists dislike CRNAs either. Your entire post is rather ridiculous honestly. What about being a CRNA would be bad really?? There are plenty of teachers, factory workers, nurses, police officers and countless other people in other professions that would love to start out at 150K per year as a new grad. I am extremely blessed to be a part of this profession and have the ability to take care of my family and live a very comfortable life. All of this and I haven't even mentioned what I like about the actual job itself. So can you see how stupid your entire premise is? There is so much nonsense in your post I wasn't even sure where to start but I think Im just going to leave it alone as I dont see any reasonable discussion to be had here. Happy holidays everyone!

Well, I appreciate your post. But haven't you seen this board? And just exactly WHY do you think the residents and attendings are dissuading us students ? Also, you didn't answer my question. I didn't ask what about your job you liked. Of course I understand CRNA is a fricken great gig ( dangerous and cheap, but great) . I would like to know why you didn't just go to med school and gather and learn a higher level of understanding of the field?? That's what I want to know.

 

[IkeBoy18]

So physicans cant collectively bargain, will ACA make things so bad that physicians will finally say enough is enough?

 

[sevoflurane]

So physicans cant collectively bargain, will ACA make things so bad that physicians will finally say enough is enough?

Maybe the older ones... Once you have 3mil, you're passive income on 6% return is 180k. Until then, I'm sticking to my plan. I can't afford "enough is enough".

What are you going to do once you say enough is enough? Start a new career? Nope.

I wish I knew enough people in the biz to start my own successful ASC/Hospital. Our orthopod group recently was bought out by our hospital. Those guys became hospital employees and are now living large...with a guaranteed salary from the hospital and a stake in the ASC. Smart dudes.

 

[pgg]

Maybe the older ones... Once you have 3mil, you're passive income on 6% return is 180k. Until then, I'm sticking to my plan. I can't afford "enough is enough".

What are you going to do once you say enough is enough? Start a new career? Nope.

I wish I knew enough people in the biz to start my own successful ASC/Hospital. Our orthopod group recently was bought out by our hospital. Those guys became hospital employees and are now living large...with a guaranteed salary from the hospital and a stake in the ASC. Smart dudes.

There's a lot of risk in ASC ownership too. I'm casually acquainted with a few people locally who bought into a new one and they're losing their asses on it. Maybe in the long run it'll work out for them, maybe it won't.

6% is pretty optimistic. A sustained withdrawal rate of 4% is probably more realistic.

 

[IkeBoy18]

Maybe the older ones... Once you have 3mil, you're passive income on 6% return is 180k. Until then, I'm sticking to my plan. I can't afford "enough is enough".

What are you going to do once you say enough is enough? Start a new career? Nope.

I wish I knew enough people in the biz to start my own successful ASC/Hospital. Our orthopod group recently was bought out by our hospital. Those guys became hospital employees and are now living large...with a guaranteed salary from the hospital and a stake in the ASC. Smart dudes.

well, I meant enough is enough and form a functioning union to collectively bargain reimbursement rates. Is this even feasible?

 

[countingdays]

well, I meant enough is enough and form a functioning union to collectively bargain reimbursement rates. Is this even feasible?

Independent practitioners can't form a union and would be involved in illegal price-fixing and restraint of trade if we tried to bargain for reimbursement. Employed, salaried docs could unionize and negotiate salaries with their employer. If/when we become government employees, we'll have a nice big corrupt public sector union.

 

[sevoflurane]

There's a lot of risk in ASC ownership too. I'm casually acquainted with a few people locally who bought into a new one and they're losing their asses on it. Maybe in the long run it'll work out for them, maybe it won't.

6% is pretty optimistic. A sustained withdrawal rate of 4% is probably more realistic.

What's the average rate of return of an investment portfolio over 10/20/30 years?

I think you and I graduated at the same time?
The rate of return since that time has been pretty darn good, hasn't it?

 

[countingdays]

What's the average rate of return of an investment portfolio over 10/20/30 years?

I think you and I graduated at the same time?
The rate of return since that time has been pretty darn good, hasn't it?

S&P 500 return averages 4.75% corrected for inflation, 6.8% with reinvested dividends

http://dshort.com/inflation/inflation-sp500-chart.html

You can take more than that if you aren't trying to leave 3mil to your heirs though.

 

[Stank811]

SRNA here. While the management of the case below sounds superb it doesn't take a physician to make this diagnosis. You even mentioned you have studied this case scenario a million times but so have CRNAs and probably AAs I would imagine. You actually had the technology and a CT surgeon immediately available to save the patient which is awesome but this is basic anesthesia knowledge. So when I hear things like "the surgeon doesnt want to have be telling the CRNA what to do when an emergency arises" I just scratch my head a bit. Having rotated through a few solo CRNA rural clinical sites I can tell you that this would never happen. Its the exact same dynamic as is seen at the larger centers. A "supervising" surgeon is not somehow blessed with more anesthesia knowledge because they work with CRNAs.

I dont plan on debating anyone on here as this is a physicians forum and I am happy to lurk and learn. I acknowledge that physician training is "better" on average than CRNA training and personally feel that certain requirements for CRNA training need to be elevated. I believe CRNAs and anesthesiologists abilities as providers are two bell curves which overlap to some degree and I hope that the solo CRNAs are falling onto the far right of the curve the majority of the time but we'll never know. Just throwing that caveat in there to hopefully ward off those who think Im just a militant SRNA trolling. Im really not. But some of the stuff posted about midlevels as if they all just follow a protocol and dont critically think is just ridiculous. Happy holidays everyone

It is easy to say that it would have been handled the same why by a solo CRNA but the problem is the majority of us on this forum that work with CRNAs will argue the opposite. A CRNA last year was manually attempting to breath a patient down secondary to elevated CO2 which they claimed was new (EMR showed 10+min of ETCO2>60) Staff eventually walked in to see how things were progressing and proceeded to take over and then diagnose and treat MH which was later confirmed. Pt did fine. How do you show that patients such as this benefit from anesthesiologist being present…you can't until the prevalence of truly solo CRNAs increases and begin doing equally complex cases. Only time will tell but I am confident based on what I have seen what the end result will be….buy more doubtful that the results will change the market forces to much

 

[hul398]

It is easy to say that it would have been handled the same why by a solo CRNA but the problem is the majority of us on this forum that work with CRNAs will argue the opposite. A CRNA last year was manually attempting to breath a patient down secondary to elevated CO2 which they claimed was new (EMR showed 10+min of ETCO2>60) Staff eventually walked in to see how things were progressing and proceeded to take over and then diagnose and treat MH which was later confirmed. Pt did fine. How do you show that patients such as this benefit from anesthesiologist being present…you can't until the prevalence of truly solo CRNAs increases and begin doing equally complex cases. Only time will tell but I am confident based on what I have seen what the end result will be….buy more doubtful that the results will change the market forces to much

Resident MD here. At the risk of elevating emotions, could I just comment that it seems like the problem is no one can prove that a well-trained, experienced CRNA couldn't do the same thing, and even may have somewhere sometime in a similar scenario. And a bad MD, or even mediocre one, might have killed that same patient. Just like all midlevels in any field, the distinction appears gray, and the problem is my predecessors have made it grayer than almost anywhere else in medicine, leading the public to wonder if there's a distinction at all. I mean, right guys, no matter what you see and think about CRNAs, it's still an opinion, no proof or law exists to support your distinction yet, does it? I'll admit right now this is a devil's advocate argument, but seems to me this is the issue at hand, at least in the public's eye. I'd love to be wrong and if there's a great MD defense, I'm all for it, but maybe the focus should be on the proof, i.e. where's the real data?

 

[Baller MD]

Resident MD here. At the risk of elevating emotions, could I just comment that it seems like the problem is no one can prove that a well-trained, experienced CRNA couldn't do the same thing, and even may have somewhere sometime in a similar scenario. And a bad MD, or even mediocre one, might have killed that same patient. Just like all midlevels in any field, the distinction appears gray, and the problem is my predecessors have made it grayer than almost anywhere else in medicine, leading the public to wonder if there's a distinction at all. I mean, right guys, no matter what you see and think about CRNAs, it's still an opinion, no proof or law exists to support your distinction yet, does it? I'll admit right now this is a devil's advocate argument, but seems to me this is the issue at hand, at least in the public's eye. I'd love to be wrong and if there's a great MD defense, I'm all for it, but maybe the focus should be on the proof, i.e. where's the real data?

Nice troll post. How about you provide a study that says otherwise and is not sponsored or carried out by a nurse association?

 

[countingdays]

Resident MD here. At the risk of elevating emotions, could I just comment that it seems like the problem is no one can prove that a well-trained, experienced CRNA couldn't do the same thing, and even may have somewhere sometime in a similar scenario. And a bad MD, or even mediocre one, might have killed that same patient. Just like all midlevels in any field, the distinction appears gray, and the problem is my predecessors have made it grayer than almost anywhere else in medicine, leading the public to wonder if there's a distinction at all. I mean, right guys, no matter what you see and think about CRNAs, it's still an opinion, no proof or law exists to support your distinction yet, does it? I'll admit right now this is a devil's advocate argument, but seems to me this is the issue at hand, at least in the public's eye. I'd love to be wrong and if there's a great MD defense, I'm all for it, but maybe the focus should be on the proof, i.e. where's the real data?

The public is unaware and will mostly accept whoever shows up on the day of surgery and will assume it's ok.

No randomized controlled comparison will ever be done because it is unethical.

I've helped crnas with medical problems many many times, I've never needed to help the other docs (other than occasionally with a block or line). Usually, the crnas do their cases without needing input from me. Fairly frequently when they do need help their initial response to the problem was just wrong. I think my experience is typical and docs who work with crnas will know that we are actually needed.

I'm happy to work with crnas and happy to help them when they need it. Asking for help is good and humble. I think more of them not less when they do. Working with a crna who won't call for help would be terrible.

Independent crna practice isn't worth the risk, especially given no cost savings to the patient in exchange for the suboptimal coverage.

 

[pgg]

What's the average rate of return of an investment portfolio over 10/20/30 years?

I think you and I graduated at the same time?
The rate of return since that time has been pretty darn good, hasn't it?

Timing is everything, if you and I had graduated 2-5 years earlier, we'd have much different overall returns ...

I wouldn't bank on a 6% SWR just because the last few years have seen a nice bounce.

Of course, the 4% SWR is a conservative number that may be better suited to those whose retirement savings just cover survival needs. Easy enough for someone with a $3M portfolio to cut back discretionary spending for a couple years if the market does poorly; harder for the guy with $300K of lifetime savings.

 

[hul398]

Nice troll post. How about you provide a study that says otherwise and is not sponsored or carried out by a nurse association?

Thanks Mr. . . uh Baller. Yes, that is my point, no such study exists.

No randomized controlled comparison will ever be done because it is unethical.

I've helped crnas with medical problems many many times, I've never needed to help the other docs (other than occasionally with a block or line). Usually, the crnas do their cases without needing input from me. Fairly frequently when they do need help their initial response to the problem was just wrong. I think my experience is typical and docs who work with crnas will know that we are actually needed.

I'm happy to work with crnas and happy to help them when they need it. Asking for help is good and humble. I think more of them not less when they do. Working with a crna who won't call for help would be terrible.

Independent crna practice isn't worth the risk, especially given no cost savings to the patient in exchange for the suboptimal coverage.

I do appreciate your view, honestly, and as a future attending I also hope and pray you are right because it means my job is actually justified. My question is how do you get the public, i.e. those determining healthcare policy, to agree with you? By public I'm not talking about your next patient, I mean the opinion of policy makers and their advisors, because they are the ones shaping our future. Maybe an RCT isn't necessary, maybe it could be a massive retrospective study. If the discrepancy is as large as you claim, the effect shouldn't be hard to demonstrate. Your cost savings claim would be hugely compelling if demonstrable. The point is, without something to point to, this seems like a lot of hearsay that the public is ignoring.

The public is unaware and will mostly accept whoever shows up on the day of surgery and will assume it's ok.

Isn't this the problem? And why is it assumed we can't educate them? Patients can be ignorant, but plenty are not, I've had many request "no residents", both from anesthesia and surgery.

 

[countingdays]

Thanks Mr. . . uh Baller. Yes, that is my point, no such study exists.

I do appreciate your view, honestly, and as a future attending I also hope and pray you are right because it means my job is actually justified. My question is how do you get the public, i.e. those determining healthcare policy, to agree with you? By public I'm not talking about your next patient, I mean the opinion of policy makers and their advisors, because they are the ones shaping our future. Maybe an RCT isn't necessary, maybe it could be a massive retrospective study. If the discrepancy is as large as you claim, the effect shouldn't be hard to demonstrate. Your cost savings claim would be hugely compelling if demonstrable. The point is, without something to point to, this seems like a lot of hearsay that the public is ignoring.

Isn't this the problem? And why is it assumed we can't educate them? Patients can be ignorant, but plenty are not, I've had many request "no residents", both from anesthesia and surgery.

A retrospective study won't work because a) when we help it isn't captured in the chart anywhere for the most part and b) no practice- MD, ACT, or CRNA accurately captures complications. A study would make those who document problems the worst seem safest and would bear no relation to actual rates of complications.

 

[hul398]

A retrospective study won't work because a) when we help it isn't captured in the chart anywhere for the most part and b) no practice- MD, ACT, or CRNA accurately captures complications. A study would make those who document problems the worst seem safest and would bear no relation to actual rates of complications.

I would think though that the study would be comparing CRNA alone institutions vs. CRNA + MD. Aren't they practicing alone in like 10 states? Also I feel like complications that matter, e.g. increase in intraoperative mortality, perioperative cardiac or neurological injury, or postoperative pneumonia would be hard to miss and hard not to document. I know rates of these are low, but if we're talking about real benefit, we have to be talking about reduction of real morbidity that has long-term ramifications, not like 5 minutes extra of SBP <90 intraop. We can't be saying we're so much better than they are, but nobody can tell the difference except us, right?
Btw, I apologize for making this into a mid-level debate, I know that's not the OP's intent. I just can't think of an exit strategy when I haven't even entered yet. This place is a panic-inducing war zone.

 

[sevoflurane]

Timing is everything, if you and I had graduated 2-5 years earlier, we'd have much different overall returns ...

I wouldn't bank on a 6% SWR just because the last few years have seen a nice bounce.

Of course, the 4% SWR is a conservative number that may be better suited to those whose retirement savings just cover survival needs. Easy enough for someone with a $3M portfolio to cut back discretionary spending for a couple years if the market does poorly; harder for the guy with $300K of lifetime savings.

Tru dat.

I think that the longer you are invested the better your chances of getting a higher rate of return. Over 5 years you may have a negative number. Over 20-30 years you're likely to get your money back and then some. Keeping up with inflation is going to be the real trick in this market.

 

[sevoflurane]

Speaking of inflation... Todays Fed announcement to scale back the stimulus early next year had a paradoxical positive shift in the market. Interesting reaction. I hope it lasts.

 

[sevoflurane]

http://www.latimes.com/business/mon...eeting-20131218,0,1911960.story#axzz2nrhUKTka