Is this a feasible way to push back from Mid-level encroachment?

Discussion in 'Anesthesiology' started by PrideOrPanthers, May 15, 2018.

  1. PrideOrPanthers

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    I have been interested in anesthesia for a long time, I love the skill set of an anesthesiologist and I find the pharmacology/physiology of the field extremely fascinating and rewarding. However, just like every other med student/pre med, am concerned about midlevel encroachment. After doing much research on the topic, it seems that the situation is that the nursing union is extremely aggressive and active and the ASA is not as aggressive in protecting the field. Do you think patient education/advertisements informing people that they have the choice to opt for an MD to handle their anesthesia care over a CRNA would be helpful in holding the place of anesthesiologists or would this cause too many problems? I ask because I feel like most people would elect to have an MD over a CRNA handling their anesthesia.
     
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  3. GaseousClay

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    docs are here to stay CRNAs are here to stay. they have already fully encroached on our field and the ASA now just tries to win small battles here and there but yes the AANA seems to have more money and more motivation to crush us. Advice is to know your sh** much better than them and don't enable them to think they can do their job better/same as you.
     
  4. Noyac

    Noyac ASA Member
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    If you look back a couple months there was a discussion about requesting an MD for your anesthesia. There were more than a few people on this forum that claimed that this would be impossible for their group. As depressing as that is I assume the ASA will not take this approach because too many docs out there do not care about the future of anesthesiology and only care about their pocket books. And the ASA would not want to offend this group of docs.
     
  5. pgg

    pgg Laugh at me, will they?
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    The ASA won't do it.

    The radiology department in my hospital has a gigantic poster in the waiting room telling patients to make sure their xrays are read by a radiologist, who is a physician with X years of residency and sometimes Y more years of subspecialty fellowship training. But radiologists aren't making money off FPs and surgeons reading their own studies. They have no cash cows to offend.

    Some anesthesiologists are making money leveraging CRNA labor. So the ASA won't do anything to impair some of its members' ability to use them.

    Two weeks ago at SCA the ASA president talked to us right before the conference keynote speech. He spent a lot of time telling us about what they're doing about drug shortages (really? who cares, the cases are still getting done!) and some more time talking about reimbursement and payment trends (important) and some more nonsense about leadership. But he didn't utter the word CRNA even a single time.

    That's what the ASA thinks about the problem. It's not an issue to them.
     
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  6. AdmiralChz

    AdmiralChz ASA Member
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    We’ve known about the problem for years. It hasn’t changed substantively in a while.

    As I keep saying and probably sound like a broken record, the situation is more dire elsewhere.

    IM and FM (outpatient) have essentially given up already and have full practice authority for nurses all over the place. Peds (again, outpatient) is under pressure mostly from sheer volume. The next frontier is EM coming to a hospital near you (first it’ll be less docs more mid levels, then more shifts, then...). Surgical critical care on the horizon, and many areas already have midwives running their own boutique birthing centers.
     
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  7. AdmiralChz

    AdmiralChz ASA Member
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    It’s interesting because Plagenhoff (spelling?) was way out in the open about it.
     
  8. Ronin786

    Ronin786 ASA Member
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    The bigger problem is that without the backing of a high-level organization, physicians that lobby against mid-levels (be it CRNAs, NPs, PAs) will only come off as petty bullies trying to protect their pockets from the caring nurses that are only thinking about helping patients.

    There's no way to present the argument that patient care will suffer, outside of having patient care suffer in a public way. And it's quite tragic.

    Just like the thread about the CRNA taking the active-MI to the OR. That won't show up in any study, but the facts are there.
     
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  9. sb247

    sb247 Doer of things
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    Yeah, I was basically told I was unrealistic for the time I demanded a doc run the anesthesia for my daughter and if I recall correctly a number said they would have told me to go somewhere else

    If the docs literally are ready to refuse a patient adamantly demanding a doc, the nurses win
     
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  10. dannyboy1

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    The bean counters and administrators who hire CRNA’s don’t give a shi& how much you know. So long as the patient arrives in PACU alive and neurologicaly intact it’s fine. The almost disasters don’t count....
     
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  11. chocomorsel

    chocomorsel Senior Member
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    Let’s not forget the quote “The ACT model is the Best model there is. Studies show it has the best outcomes out of ALL the models”
     
  12. GaseousClay

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    like i said theyve fully encroached the field. my point is don't be a dumb, lazy a$$ and allow the CRNAs feel like they are justified to encroach. thats the best one can do, but that's really only for personal satisfaction.
     
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  13. atomheart

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    At my hospital patients rarely get a say in who treats them regardless of the specialty. I feel like I previously had this idea about scope of practice and encroachment that doesn't reflect what's actually going on. Within a hospital there are teams, and within those teams physicians can train midlevels to do whatever they want within the full scope of medicine and surgery. It may sound tedious, but the IR staff here trained their PA and NP to do central lines, permacaths, ports placement and removal, piccs, thoracentesis, paracentesis..procedures that occur frequently and that anyone can be trained to do with an ultrasound or fluoroscopy. They're doing almost all the bedside procedures in the hospital, and the physicians here are ok with that because there is a non existent complication rate. The patients are too, and when a patient wants to see a physician only often the doc goes to bat for his midlevel.

    Now, what's going on in anesthesia is a decades long hostile work environment between midlevels and physicians. But it's not a universal problem among physicians, and therefore physicians as a whole are not concerned. The ASA has a spoken stance on the relationships of anesthesia providers, and insofar as a minority of physicians in a minority of hospitals are truly having issues with midlevels they will leave waters undisturbed.
     
  14. sb247

    sb247 Doer of things
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    The doc shouldn’t be “going to bat” against a patient that wants a doctor instead of a midlevel
     
  15. atomheart

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    That's not the point. The patient doesn't get a list with checkboxes of who they want to touch them. Such a list would not be efficient.
     
  16. sb247

    sb247 Doer of things
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    Patient autonomy is not efficient, but it is more important than efficiency
     
  17. atomheart

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    Sure. You tell that to some jerk throwing their foley bag at everyone coming to see them. In my experience that's the patient asking to see only the doc. The ones like you are few and far.
     
  18. dannyboy1

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    Yup. Only the ones that seem to have the most personal satisfaction in this field are the aforementioned lazy @$$es. The ones that don’t even pretend to be a doctor anymore. The ones who will do whatever some surgeon or administrative person will tell them. The ones who “supervise” without ever seeing the patient even once. For them it is a great gig. Sit on your ass drink coffee and make a lot of money.
     
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  19. GravelRider

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    Short answer: no

    The ever increasing drive towards consolidation in American healthcare means there will be continued pressure to cut costs in order to increase profits. A larger supply of “providers” means these conglomerates can cut the costs associated with the labor. That’s all there is to it. The only “quality” that matters to these organizations is “quality” that results in some kind of government subsidy. Healthcare is about 30-50 years behind other American industries that were able to cut labor costs by outsourcing labor overseas. You can’t exactly have an underpaid person in Indonesia providing anesthesia so the next best strategy is to increase the supply of labor. The AMA has long restricted the number of medical school and residency spots, but there is no such restriction on nursing schools. That’s where we’re at.

    Anesthesia is not even close to being the only field in this mess as mentioned in other posts. Some of the problems in primary care have come about purely out of need. Primary care has dismal pay in many regions and with enormous medical school debt, it is not exactly an attractive option (plus, the days of being a true general practitioner where you served your community are long gone...see above paragraph on consolidation...you are there to serve as an entry point in these massive systems so you can shuttle patients off to more financially rewarding specialties in the system).

    The only hope that I see is that there will eventually be pushback for more personal medical care and real quality. We have seen this in other industries...craft beer is probably the best example. This happens on a local level. My advice is to get more involved in your local or even state medical groups. The 4:1 supervision factories tend to cluster around each other while the high percentage of hands-on practices tend to cluster as well. I don’t think this is an accident. Some of this is supply, but some of it is also driven by other forces such as surgeon and patient expectations on a local/regional level.
     
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  20. narcotics999

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    If ASA does not support us, what don't WE do something instead? We can set up our own pro-MD organization; we can promote ourselves through social medium etc.

    Patients mainly care about safety and cost. If cost is the same (for the patient), even dumb patients know the difference between nurses and MDs. If enough patients inquire about MD anesthesia service, administrators, surgeons may start to ask for it too.
     
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  21. FFP

    FFP Grunt, cog, body, pompous ass
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    You are so friggin' naive they should make you pay a tax for it.
     
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  22. GandalfTheWhite

    GandalfTheWhite Chillin in Isengard
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    LOL so many docs on here complaining about how the ASA doesnt have our best interests at heart or that theyre bought out, but dont bother running for the elected positions themselves. Everyone likes to complain but no one wants to actually do tangible things towards making meaningful change.
     
  23. Noyac

    Noyac ASA Member
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    I like your approach. Tell me, what’s your position held?
    I do hold a political position. And I can tell you that the ASA brass is a tough nut to crack. They are extremely narrow minded institutional entities. And so are most of your state societies. They are all made up of a majority of academics that don’t see things like those of us in the trenches. They support MOCA and it s money generating monopoly. They train nurses to take our jobs and to feel like they are our equals. They are IMO a tremendous hurdle because they are politically connected. I have been beating my head against these wall for over 5 yrs.
     
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  24. GandalfTheWhite

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    Bruh.. Im a damn medical student. I dont have the experience, nor the expertise to even hold a position at any meaningful level. The societies are made up of academics because, by and large, PP docs dont bother to run for these positions.
    Sure they may screw the specialty by increasing residency spots and training CRNAs, but PP docs still employ those CRNAs to increase their income, so its not as if PP docs are not contributing to the problem. No one will turn down a bigger salary to take a political stand, which is why changing the makeup of the body that supposedly represents anesthesiologists is the most plausible route to go through.

    And thank you for actually doing something about it by holding a political position in an attempt to help out the profession.
     
  25. dannyboy1

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    Overall, there is nothing to be done. CRNA’s have been around a while and have established a reasonable record of safety and efficacy. They are not going anywhere. Overall this will probably lead to lower salaries/worse hours for everyone. We are not special and are not immune from market forces. For all the hand wringing on sdn about dangerous and scary CRNA’s the fact remains that if they were killing patients on a regular basis we would not be in this position ....
     
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  26. flightnurse2MD

    flightnurse2MD I’m just a Maserati in a world of Kias
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    Plagenhoef is a beast! Love that guy.
     

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  27. Modanq

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    One of the other sides of the coin to consider is placing yourself in the shoes of a standard RN. Just like with medicine there are internal hierarchies and financial levels that exist in the RN/PA/Midlevel world. Simple economics and market demands. If you get to know the SICU nurses or maybe a family member who is a RN you learn more and more about the pathways/ambitions. The SICU RNs disparage the floor nurses, The PACU RNs can't stand the OR RNs. Each has more or less experience and pay.

    Second, there are many different pathways for RN, BSN, RN from prior BS, Accelerated RN. I don't even know how many schools and programs exist - online and classroom based. But if you start off on the floors there are some that gun for the ICU, or "more lucrative" or more "clinically demanding" work environments. For those motivated enough they start thinking bigger i.e. monetary, admin, resource RNs, NP, IR NP, Cards NP, ER NP, Derm NP, CRNA, and even CTPA. The crux of the problem is there are a massive amount of 25-35 year old RNs. From that a percentage have ability, ambitions, families, economics, and also want autonomous practice, prescriber level freedom (which is difficult to prove to be unsafe in the gross sense). Plus many of these paths tack on a PhD so you can call yourself a doctor. All the while getting "clinical experience." So many start trying to get those jobs which exist due to demand and also have on the job degrees.

    Furthermore, the time medical students spend doing combined undergrad degrees or 5 year pre-med tracks + research, 4-5 years medical school or 8 years MD/PhD, to then tack on 5-6 years of residency only to then find out that you actually liked derm not vascular surgery whereas the RNs start at 22-25 years old and have "5-10" years of some vague and often protocol experience ... they then trickle through to Admin, CRNA, NP etc. It becomes very hard to distinguish a mediocre MD early career versus a clinically experienced RN in the technical sense, moreover you start relying on one another. Ex EP Cards NP coming to program the pacer before the CTPA start prepping the leg to take veins while the CRNA helps you float the swan only for the CV surgeon to do the LIMA, and then since it was preserved EF straight forward CABG you admit to the NP service but if it was a transplant it goes to the attending service...What the qua?

    Moreover, you all know those physicians where you question the level of competence of MDs...And that is the problem. Its a bellcurve of MD versus Midlevels. The distribution of the bellcurve does overlap....You have to figure out how to move the bellcurve apart. That means politically, educationally, administratively, Perception (Marketing to patients but also to other physicians). One of the main reasons that anesthesiologists exist is when the CV surgeon wants a critical case done they turn to the CV anesthesiologist. When the ENT has difficult airway peds cases, they use the Peds anesthesiologist. When any surgeon needs a question about anticoagulation they ask the MD. So we have to continue to be invaluable in the hospital. Look at university of utah - hell they are running their own stress echo lab for preoperative care. Look at vanderbilt - they have their own post ICU clinic. Its not an answer but its something.

    Just my 2 cents.
     
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  28. Man o War

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    Their “established safety record” cannot be divorced from supervision and involvement of anesthesiologists though. That is the crux of this whole issue. The independent CRNA is a rare bird.
    My measuring stick after working with CRNAs for many decades is would I let one take care of me unsupervised? The answer isn’t just no, it’s hell no.
    We have CRNA graduates coming out who have only ever observed certain cases and procedures.
     
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  29. dannyboy1

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    I guess you have not seen what passes for anesthesiologist “supervision” in a busy 4:1 practice. Many docs are not even seeing the patients or know what is in the room under their name. It’s independent practice in all but name.
     
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  30. Man o War

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    I have worked 4:1 and that isn’t how it was at all.
     
  31. Maverikk

    Maverikk ASA Member
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    I think the most frustrating part is the hostile environment, which by the way doesn't exist everywhere. For more sub specialty areas like cards/IR/derm/surg the midlevels listen when the attending speaks because they value their input and the bell curve overlap is smaller. Are they taking positions once filled by docs? Yes but no where near our predicament. One solution not mentioned, and the best I think, is to use AAs. Yes people may rant and rave that they will eventually demand independence but I don't see it either legally or culturally. I've heard of smart groups out there in many states moving toward mostly AA hiring, mostly on the west coast which has more MD only groups to begin with. The devil is in the details and how many people you're training to be part of your team vs. how many you're training to replace your job. Yes, there are sub-specialty midlevels taking roles for more lazy docs in that field, but if you're training hard and have the knowledge to provide input on anticoagulation, difficult airways, fluid management etc. you're adding value to the hospital the midlevel, surgeon and admins (eventually) see. The bottom line in my mind is stay on top of your knowledge so you're providing essential input, support AAs (and stop dooming and glooming about the future, bottom line is there is a surgery center in BFE that needs people to fill it, and I want a team player to do it) and try to run for admin/political positions in your hospital environment. Even if you just want that chillax job at the surg center, work with AAs who want to work with and not against you. This solution avoids trying to fight with CRNAs which is a losing position, instead politically just say yes we need more anesthesia providers, let's have ones that legally and culturally work with anesthesiologists. No more fighting but putting a positive spin: we're finding a solution to providing anesthesia providers with skilled, certified AAs.'
     
  32. Man o War

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    This is what my previous group did. Worked out fine other than the foot stomping and drama when the first group of AAs started. I’ve stayed in touch with them, and they no longer hire CRNAs at all. They’re letting attrition occur, eventually they will be an all AA/doc mixed model. They have been pleased with the quality of the AAs they’ve hired as well.
     
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  33. VA Hopeful Dr

    VA Hopeful Dr Senior Member
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    For elective things, it should be doable and not particularly onerous.

    I'm FM, if a patient insist on seeing me and no one else in the practice will do, it might mean they have to wait a little bit longer but it can be made to work. That's how it should be for anything that's elective.
     
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  34. atomheart

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    I never said physicians refused patients expressly wanting to see them. I said they'd go to bat for midlevels (and nurses, and other staff).

    Yes, I suppose that means patients have a choice if they ask, but I've never once seen it presented that way by anyone ("do you want an NP/PA or a physician doing this line?"). Therefore, I would still say that a patient at my hospital rarely gets a say in who treats them.
     
  35. FFP

    FFP Grunt, cog, body, pompous ass
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    Let's not confuse monkey duties with real medicine. Placing lines, tubes, needles etc., especially under imaging guidance, can be done by any trained monkey. I did not go to medical school, residency or fellowship for those; I did it for the knowledge and scientific thought process, and that's where I run circles around most midlevels (and surgeons). That's where sheer numbers don't help much (versus procedures where it's all about how many one has done).

    I find it sad when anesthesiologists try to define themselves as airway experts or procedural experts. That's dumb. Those are the areas where midlevels (and other non-anesthesiologists) will take over, as soon as technology permits (and you can already see the lack of a difference when intubating with a glidescope). Ultrasound-guided nerve blocks? Big deal. Lines, neuraxial blocks? Same. Anything a CA-1 can do, at the end of the year, a CRNA will do. Anybody who can play a point and shoot 3D video game can be trained to do a procedure. We should be the periop experts, the best physicians to deal with any perioperative problem, pre-, intra- and postop, not just procedural monkeys.

    This all stems from the reimbursement policies, which favor proceduralists. Now imagine if most proceduralists would not be physicians anymore, which is where all of this is heading (especially since procedures are reimbursed better than gray matter). The most protocol-based and dumb activities in medicine are the procedures, hence they are the most ripe for takeover. The entire ACT model is built on this concept: anesthesiologist as the brain, CRNAs as "surrogates".
     
    #34 FFP, May 16, 2018
    Last edited: May 16, 2018
  36. VA Hopeful Dr

    VA Hopeful Dr Senior Member
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    And admittedly things in the hospital are a bit trickier as you often can't wait to have things done like you can for elective or outpatient visits or procedures.

    If I'm scheduling for something like a knee replacement or sinus surgery, I should be able to request and receive anesthesiologist only care the same way as a patient at my practice can ask for MD only care and get it. It may mean a delay, or not having the appointment of the exact time you wanted but it can happen.
     
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  37. TheLoneWolf

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    At my residency program, four of the residents in the CA2 class took a week out of their vacation time for surgery as they are fully covered by the generous university health plan. Mostly ENT stuff, all had CRNAs do their cases and all had requested an anesthesiologist or resident. All rebuffed on the day of surgery by lazy attending wanting to run the board as they see fit. The very same guys they regularly work with.
     
  38. atomheart

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    I agree with what you're saying. Patients are entitled to decide who treats them. Usually they make the assumption that whoever is treating them is qualified, and they don't make a fuss. If they are given the option, I think they would choose the anesthesiologist every time.

    I don't honestly know if what the OP is asking is feasible if everyone who comes into the hospital asks that they be treated by an anesthesiologist for any monitored procedure. Maybe. I suspect that a CRNA would say it isn't, and they would feel threatened by the concept of explicitly giving patients a choice. Most patients don't know the difference, and apparently some CRNAs don't either. I doubt most people are going to put that much work into their care in the first place. In my hospital patients aren't asked if they want an anesthesiologist or a CRNA, and therefore most get the default care. In other areas of the hospital relationships between physicians and midlevels appear to be different.
     
    #37 atomheart, May 16, 2018
    Last edited: May 16, 2018
  39. GandalfTheWhite

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    So then maybe the first step should be the most obvious: make sure the patient is properly educated about the difference between an anesthesiologist vs CRNA, and then ask them which one they prefer. If anesthesiologists are on hospital boards/committees, then making this hospital policy would be a step in the right direction.
     
  40. MoMoGesiologist

    MoMoGesiologist ASA Member
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    Well what if I like doing procedures and don't want to use my brain!?
     
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  41. dannyboy1

    10+ Year Member

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    Problem is that surgeons ( for the most part) are not interested in our medical opinion or judgement. They want us to put the patient to sleep so they can do the case. That’s it. Ever notice how the most beloved anesthesiologists are those who never cancel a case and rush through the preop so you can get in the room faster.
     
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  42. FFP

    FFP Grunt, cog, body, pompous ass
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    Then don't be surprised if your job will go the midlevel way at some point in the future.
     
    #41 FFP, May 16, 2018
    Last edited: May 16, 2018
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  43. FFP

    FFP Grunt, cog, body, pompous ass
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    And that's why the AANA is winning. Without the surgeons' complicity, CRNAs wouldn't even exist.

    Surgeons like to surround themselves with yesmen, and have it their way in many hospitals. As long as an anesthesiologist is much-much easier to replace (maybe even with a CRNA) and brings in less money than a surgeon, I expect our downfall to continue (at least in certain markets).
     
    #42 FFP, May 16, 2018
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  44. GravelRider

    GravelRider SDN Lifetime Donor
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    Why not be a carpenter then? A good contractor makes good money.
     
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  45. SaltyDog

    SaltyDog Keeping the Forces of Entropy at Bay
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    Or an Orthopedist!
     
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  46. GravelRider

    GravelRider SDN Lifetime Donor
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    Essentially the same thing...though I may argue that a contractor has to problem solve more often.
     
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  47. VA Hopeful Dr

    VA Hopeful Dr Senior Member
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    And if they don't ask, or if the request can't be granted on the patient's schedule, I have no objection to doing whatever the standard protocol is. If you come in with a gun shoot wound and don't want the X-race trauma surgeon, then your choices are A. Leave or B. Let the on-call surgeon treat you. I completely get that we can't always do whatever the patient's want.
     
  48. pgg

    pgg Laugh at me, will they?
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    Well, per the other threads, your department appears to be considerably more f'd up than the average.

    On the bright side, when you graduate, wherever you go you'll end up in greener pastures.
     
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  49. kmurp

    kmurp Junior Member
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    Do none of you work in PP jobs where your group willingly employs CRNAS? Our group does and I see no problems.
     
  50. AdmiralChz

    AdmiralChz ASA Member
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    The one I’m joining next month does. They have no issues (or at least, minimal issues). The line is so long with new grad applicants that if any of the nurses give any grief they are shown the door swiftly. Strict rules on procedures - a-lines only, and only when the attending is in the room.

    Not everywhere has terrible practice environments. Just be clear and concise about roles, and don’t roll over for “scope of practice” arguments.
     
    #49 AdmiralChz, May 16, 2018
    Last edited: May 16, 2018
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  51. Man o War

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    Dang guys/gals. Surgeons aren’t idiots, where is this coming from?
    This.
    Exactly why my old group started with AAs. Too much attitude, too much of the time.
    They’re working under your license, so you make the rules.
     
    #50 Man o War, May 16, 2018
    Last edited: May 16, 2018
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