For those who work in an ACT model

[unkemptmiso]

I’m a med student, first time poster here-

Quick question, to those of you who work in an ACT model supervising nurses, in what ways do you find your job rewarding? As a med student, I mostly meet docs at my university who do their own cases or supervise residents 1:2 (sometimes 1:1) and they’ve been very vocal about how rewarding it is to personally take care of their patients and provide anesthesia safely. I can definitely see how rewarding this must be, but for those who might be more removed from the actual delivery of anesthesia themselves, what keeps you going?

Thank you for your input!

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[deleted162650]

I’m a med student, first time poster here-

Quick question, to those of you who work in an ACT model supervising nurses, in what ways do you find your job rewarding? As a med student, I mostly meet docs at my university who do their own cases or supervise residents 1:2 (sometimes 1:1) and they’ve been very vocal about how rewarding it is to personally take care of their patients and provide anesthesia safely. I can definitely see how rewarding this must be, but for those who might be more removed from the actual delivery of anesthesia themselves, what keeps you going?

Thank you for your input!

The paycheck mostly

 

[Consigliere]

I stupervised (intentional spelling) for many years. Now I do 80% of my own cases (other 20% of time is running the board while on call, etc.) and am 80% happier. We do an anesthesiology residency to provide anesthesia, not supervise it's administration. Definitely 2 schools of thought on this though...

 

[deleted126335]

Agree with above posters.
Professional satisfaction tends to be higher for docs who do their own cases.
Paycheck tends to be lower.
MD Administered anesthesia is getting far less common for economic reasons. So there are far fewer options for those who would rather do their own cases. Off the top of my head, excluding residents in training I would estimate that it is about 15-20% of anesthetic cases in the US. Pure guesstimate on my part.

 

[AdmiralChz]

Agree with above posters.
Professional satisfaction tends to be higher for docs who do their own cases.
Paycheck tends to be lower.
MD Administered anesthesia is getting far less common for economic reasons. So there are far fewer options for those who would rather do their own cases. Off the top of my head, excluding residents in training I would estimate that it is about 15-20% of anesthetic cases in the US. Pure guesstimate on my part.

I dunno, it seems anecdotally MD only is still very prevalent out west. And still frequent PP cardiac is own room as well, even on the east coast from the several groups I interviewed with. Cardiac is the exception, though, and overall definitely becoming more and more rare, though.

 

[OneFellSwoop]

Depends how it is set up and your own active involvement. I live in a region where it's basically ACT or nothing. Would I like to do my own cases, sure, but we are medically directing as opposed to supervising so there is certainly more involvement and planning that I do for an anesthetic. I have several additional leadership positions, so moving the hospital and ASC in what I consider a positive direction (though unpaid) also adds to satisfaction.

 

[narcotics999]

200% happier. I would be 300% happier if less Medicaid pts. F ACA.

 

[Hoya11]

I’m a med student, first time poster here-

Quick question, to those of you who work in an ACT model supervising nurses, in what ways do you find your job rewarding? As a med student, I mostly meet docs at my university who do their own cases or supervise residents 1:2 (sometimes 1:1) and they’ve been very vocal about how rewarding it is to personally take care of their patients and provide anesthesia safely. I can definitely see how rewarding this must be, but for those who might be more removed from the actual delivery of anesthesia themselves, what keeps you going?

Thank you for your input!

Talk to some docs out in PP. Just because you have CRNAs and you are supervising 1:3, that does not mean you are disconnected from delivering anesthesia.

Im disconnected from charting data, gathering supplies, and very minor intra-case adjustments like sevo up sevo down, 50 mcg more fent, 10 more roc, the usual maintenance stuff...

Every single day I am doing airway, neuraxial, alines, central lines, blocks all personally. Either as the result of the CRNA inevitably having trouble in one of the rooms im covering (more rooms more chance of this) or as the result of me just doing them to save time. If im busy with something more important, go ahead start the aline, let me know if you cant get it and need help. If I have time, as soon as were asleep I do it and CRNA does other stuff, 2nd IV, OG, starting drips, etc...

I dont have experience as an academic attg, but comparing my PP gig to my residency, I feel that my days are way more full/interesting as a PP attending. Given that you have more rooms, one of them is inevitably going to be interesting in some way and requiring your expertise..

 

[GA8314]

We sit our own cases from time to time. We also work in ways in which we can give breaks and lunches. So, we can give breaks and lunches at times, and start the case, or wake up and take to PACU.

Mostly, we are ACT model. I don't frequently place LMA's, but will frequently intubate when supervising. I don't "steal" them all from our NA's but make a point to tube 1-2 out of 3 or 5 cases or so. More if I want. Less if I want.

Remember, when you are supervising, in many ways it's more stressful. I agree it can be less rewarding. However, when we do high volume ortho cases, we are doing 2-4 times the regional that we would otherwise. I'm also exposed to 2-4 times the number of difficult airways etc.

So, less personally rewarding perhaps, but less skills? I'm really not sure about that.

As a resident I was hung up on the concern that I'd somehow "lose my skills" in an ACT model. I just don't see this happening. Maybe our practice allow for a bit more flexibility than most ACT practices (sitting rooms here and there, and allowing for breaks etc.). But, even still, you don't lose the feel for the OR as much as you might think. There are plenty of ways to stay relevant. Indeed, you could argue this both ways.

Make the best of your practice model. Frankly, you don't control that as much as different regions have different models. My area is mostly ACT with some mostly MD/DO only about 1 hour away.

We do probably make more money than the average doc only. Although, they can still do very well.

The good part about the ACT model is if we lost every political fight I foresee a "collaborative model" actually being more common where we all "practice to the full extent of our training". What this means is anyone's guess, but let's just say I would not be devastated to finish out my career sitting my own rooms and making a bit less.

Again, just make the best of your situation. Control the procedures as others have said. We do that. Our CRNA's do very little procedures, and from me never any lines of any kind. Some of my partners will supervise a rare A-line or Neuraxial but it's not common for us. Never any regional.

In fact, our CRNA's know that our group is not the group to come to if you want to be a CRNA "hotshot" doing just about everything. It's just not the right fit for someone who wants to do that. It is what it is. Sometimes you need to say "no". We do, and I will continue to drive that in my group.

In fact, most of the younger docs in my group have a more strict policy towards CRNA's doing things like neuraxial and A-lines than the older guys. Probably as a direct result of experiencing new levels of rhetoric from the likes of the AANA.

 

[Shimmy8]

In PP supervising 3-4:1 at all times.

Level II trauma, super high acuity vascular and thoracic, big backs, tons of joints.

I do a **ton** of procedures. Lots of intubating. Even more mental hurdles every day coming up with plans on sick, fat as f*** patients daily.

I don’t know how you could come out of each day not feeling connected to your patients if you make it a priority to be on top of your game and involved in care. Sure I have some partners that do the bare minimum supervising, but spending the extra few minutes in each room with patients both in holding, OR, and PACU goes a long way.

 

[psychbender]

I have done some moonlighting during my time in the military at two civilian hospitals with ACT practices. At those two hospitals, the anesthesiologists could definitely lose skills, as they had essentially no presence in the OR. When I was there, I made a point of regularly going back, helping induce or manage the airway, or doing procedures (lines, spinals) to help move the case along safely. Several of the CRNAs made comments that I was more involved than most of the staff working there full-time. The partners preopped, signed the chart, and took care of PACU. A few would enter their rooms, if needed. Several never entered rooms. These practices exist, and are what color the opinions of many others on this forum and in hospital administration.

 

[parcus]

Interesting, sounds like it depends a lot on the anesthesiologist’s attitude. I work in a country without CRNAs, and my general impression is that it favors the worse anesthesiologists by creating a shortage of providers. That way they get paid the same as people who do more complex anesthetics even though they are esssentially glorified CRNAs. At least for now I think the ACT models makes a better use of our skillsets.

 

[Arch Guillotti]

I have done some moonlighting during my time in the military at two civilian hospitals with ACT practices. At those two hospitals, the anesthesiologists could definitely lose skills, as they had essentially no presence in the OR. When I was there, I made a point of regularly going back, helping induce or manage the airway, or doing procedures (lines, spinals) to help move the case along safely. Several of the CRNAs made comments that I was more involved than most of the staff working there full-time. The partners preopped, signed the chart, and took care of PACU. A few would enter their rooms, if needed. Several never entered rooms. These practices exist, and are what color the opinions of many others on this forum and in hospital administration.

Were these anesthesiologists claiming medical direction?

 

[psychbender]

No, they billed medical supervision, so billing was kosher.

 

[GA8314]

I have done some moonlighting during my time in the military at two civilian hospitals with ACT practices. At those two hospitals, the anesthesiologists could definitely lose skills, as they had essentially no presence in the OR. When I was there, I made a point of regularly going back, helping induce or manage the airway, or doing procedures (lines, spinals) to help move the case along safely. Several of the CRNAs made comments that I was more involved than most of the staff working there full-time. The partners preopped, signed the chart, and took care of PACU. A few would enter their rooms, if needed. Several never entered rooms. These practices exist, and are what color the opinions of many others on this forum and in hospital administration.

I know they exist. These practices are terrible for us. All they do is feed the CRNA political machine and create militant CRNA's.

 

[GA8314]

No, they billed medical supervision, so billing was kosher.

ah... didn't see this. well, at least it's not fraud. Still total BS.

 

[chocomorsel]

I personally have a very difficult time juggling rooms, so therefore prefer to do my own cases. I can't multitask like that without forgetting ****.

 

[chocomorsel]

Interesting, sounds like it depends a lot on the anesthesiologist’s attitude. I work in a country without CRNAs, and my general impression is that it favors the worse anesthesiologists by creating a shortage of providers. That way they get paid the same as people who do more complex anesthetics even though they are esssentially glorified CRNAs. At least for now I think the ACT models makes a better use of our skillsets.

You are a lucky man or woman.

 

[skypilot]

Depends how it is set up and your own active involvement. I live in a region where it's basically ACT or nothing. Would I like to do my own cases, sure, but we are medically directing as opposed to supervising so there is certainly more involvement and planning that I do for an anesthetic. I have several additional leadership positions, so moving the hospital and ASC in what I consider a positive direction (though unpaid) also adds to satisfaction.

What does a supervised room cost at 3:1? For math simplicity assume the CRNA makes $200k. The Anesthesiologist makes $390k. Therefore the supervised room costs $200k plus 1/3 of the Anesthesiologist or $130k. That equals $330k. At some point in your career you should be able to say "I don't want to supervise" I will do my own cases for $330k. And call is not included! Maybe not your first job, but eventually docs in all specialties need to take control of their own destiny. And you need to write it into the contract. Because the corporations that are taking over Anesthesia see the supervisory cost as variable. They feel they can squeeze it till we are supervising 5:1. And its up to us to say "no."

 

[chocomorsel]

What does a supervised room cost at 3:1? For math simplicity assume the CRNA makes $200k. The Anesthesiologist makes $390k. Therefore the supervised room costs $200k plus 1/3 of the Anesthesiologist or $130k. That equals $330k. At some point in your career you should be able to say "I don't want to supervise" I will do my own cases for $330k. And call is not included! Maybe not your first job, but eventually docs in all specialties need to take control of their own destiny. And you need to write it into the contract. Because the corporations that are taking over Anesthesia see the supervisory cost as variable. They feel they can squeeze it till we are supervising 5:1. And its up to us to say "no."

That’s what I do and about what I make. Worth it to me. I am not a good supervisor.

 

[coffeebythelake]

would also prefer to do my own cases, but at current place (large academic teaching hospital) with residents and crna's this doesn't happen.