MD anesthesiologists in university centers?

[Ronin786]

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How do you stay up to date with your skills when you're supervising? Mainly airway skills, lines and such. Especially if you're with a resident and they're going to intubate and put in most of the lines.

 

[IlDestriero]

I work at a place where I can do my own cases. I also steal all the lines from the CRNAs and the difficult airways as well. When I work with a resident or fellow, I usually let them do it. Sometimes we split the job, they get airway and central line, I take the Aline. It's fair, and fast.

 

[GA8314]

I agree. The last things we need to do is pick each other apart within our profession. Adaptability is one of the common cores we must demonstrate to become board certified.

There are pros and cons to both situations. There are personal preferences for one over another. No matter why you are in one practice model or another, we all have the same goal: excellent patient care.

I believe the best way to achieve that is via physician anesthesiologist care. Whether it is provided in an ACT or solo model, the physician is ultimately responsible for the success of a good anesthetic.

We battle constant antagonism from midlevel practitioners. I see no good place for it among each other. It seems kind of silly.

Agreed. Those practicing solo care love to suggest that's the best way, and those practicing ACT care do the same, typically. I enjoy our model of practice, but I could also see how solo would be nice in many ways.

 

[GA8314]

Yeah, we have residents where I'm at. Our CRNA's don't do any difficult airway, no lines of any kind. No regional. Infrequently, the SRNA's will do a spinal or A-line but it's very infrequent. They do those at the other places they rotate through. You know, the places where the docs sign charts......

 

[Arch Guillotti]

Any supervision situation where the CRNAs don't work for the MDs is bound to fail. Just the way it is. When their financial incentive is aligned with the medical direction things run extremely smoothly.

It certainly is a different dynamic when you employ the nurses and sign their paychecks. I don't think every other scenario is doomed to fail though.

 

[chocomorsel]

The problem is not supervision. The problem is greed. Anybody could provide safe anesthesia with two rooms running, even with mediocre CRNAs, but no, we do 3 or more. That's like taking care of 5 times more ICU patients: just a subpar quality race to the end of shift.

No truly good doc will enjoy this. Too many balls in the air increase the chances that one won't be caught in time, sooner or later. It's just assembly lane and shift mentality, not quality care. But, hey, we're producing all that profit, so it must be good medicine, right?

Much better to sit in a room and think about how I could improve the care of this patient, or the next, or the one after that, or just read stuff to improve the care of the next thousand. Great docs are not the ones who just do, do, do, but mostly the ones who read, read, read, do, read more. Otherwise one just ends up being like an old CRNA, all monkey skills and experience, pretty much a one/few trick-pony.

I am sorry, but I will never believe that quality of care can happen with 3:1 supervision, except with very long cases, or very good midlevels (at which point it's basically independent practice with a firefighter preop monkey doc as resource).

Agree wholeheartedly. When I was supervising I felt the exact same way. I couldn't keep all the cases straight in my head, I wanted to break my phone by throwing it across the room each time it rang, and seems like no matter how fast I was moving, it wasn't fast enough. And I am a skinny girl who moves fast.

I much prefer solo practice now. I have time to think thru each case, in each case. Not be a juggler with all those damn balls in the air.

 

[chocomorsel]

Any supervision situation where the CRNAs don't work for the MDs is bound to fail. Just the way it is. When their financial incentive is aligned with the medical direction things run extremely smoothly.

Not always. When one of the MD's is besties with a CRNA, that CRNA can be disrespectul and a jerk without any consequences since their bestie is the Chair. No bueno.

 

[Hoya11]

yeah "besties"

 

[IkeBoy18]

And you're already in the "let's make as much money as we can, and then get out of this business" phase. Not that I disagree... 🙂

As an employee, I couldn't give a f*ck that my employer rakes in the dough for working my butt off in 3 rooms. What's this, residency for life? Work 10-12 intense hours/day, then go home and sleep, then start again in the morning, while waiting for the weekend?

For the first time in years, I actually look forward to going to work. CCM can be intense, but nothing like anesthesia in a profit-/surgeon-focused setting. I have way more input (as a fellow) in the care of each of my 10 ICU patients than my 3 OR patients (as an attending).

Im on neuro icu and this weekend i had 21 pts each day, 13 icu, 6 NIMU, 2 floor pts.. talk abt a cluster. Just me and a brand new 3 day fellow, who also had 21 pts of her own. Talk about a cluster.

 

[Hoya11]

I'd personally rather supervise someone stabbing needles into my eyes instead of work in an ICU. Way low return on your investment of effort in terms of actually helping people vs futile care, but some people can just not see that. (IMO ICU is the area of healthcare most in need of a huge general overall and rethinking about WTF we are doing with these people)

Also, just want to throw another positive view out about supervision. When you are as resident you are learning to be an attending (like the one who is supervising you). You see them juggling. I genuinely do NOT want to sit in the room on the 3 hour lap chole, and am happy the CRNAs can help with grunt work. It makes my day more cerebral. Im not running to the anesthesia room getting suction tubing/meds. Heres the plan, call me for induction, embrace it 😉 but i would also be happy doing my own cases if the job called for it, but i would certainly think its 1. easier, and 2. inefficient.

 

[bronx43]

I'd personally rather supervise someone stabbing needles into my eyes instead of work in an ICU. Way low return on your investment of effort in terms of actually helping people vs futile care, but some people can just not see that. (IMO ICU is the area of healthcare most in need of a huge general overall and rethinking about WTF we are doing with these people)

I could not agree more about this. Nothing even comes close to the ratio of wasted resources to value add that embodies the modern ICU, which is really modern healthcare taken to its logical conclusion. This is especially true at large academic or tertiary referral centers where the ICUs are nothing more than corpses on machines. Sure, every so often you have a young healthy person that has the full potential to recover, but this is the rare exception - not the rule. I have no doubt that as the health care system crumbles, intensive care will be whittled down substantially.

 

[G-Man82]

Medical ICUs more closely fit that description. I have a lot of patients in my surgical unit who can potentially leave the unit. Plus, nothing is more gratifying then getting someone through a horrible bout of ARDS and actually getting to experience the gratitude from the patient and family afterwards. I happen to love it, and don't think being a 100% general anesthesiologist would have cut it for me. Different strokes for different folks. We're ideally suited to the ICU and I think by positioning ourselves there we bring a whole new perspective on Anesthesiologists as more than the man behind the mask who may or may not be a doctor. Patients and families remember me in the ICU, surgeons listen to what I say more closely, and best of all I'm more my own boss when in the unit. Can't say that for the OR.

That being said, 23 patients for an intern and fellow is a crime. ICU needs to be restructured pretty much every where if we are to get people to view it as more than just the place for futile scut work. As far as going to the unit and dying? That's more a problem with US Healthcare than critical care in general.