Medical Direction...Does it have to be this way?

[pd4emergence]

I have followed the CRNA/MD debate here and other places ad nauseum. I try to look down the road of what would happen if and to be honest with you I would not mind seeing the system change. I work in a medical direction practice. 50-60+ hours a week, I see every patient before we go to the OR, come up with an anesthetic plan, and hope this plan can be carried out by the NA staff in the room. Many times I change my plan according to certain NA's being better at certain things. I am present at every induction and at every emergence. I start every CVL, do every block, nearly every spinal, and usually the patient's initial IV. I am actively involved in every one of my patients' anesthetics. At any one time I have 3-4 pt's in the OR, 2 or so patients in the recovery room, and 1-2 pt's ready to see in the preop area. There are times when I am so busy that I don't pick up on things as quickly as I should and I constantly live in fear that one day I will miss something that would have made a huge difference.

In regards to the above, this is the only way I could practice in a place where medical direction is the norm. I can't imagine what supervision is like. Probably like being a fireman except with a potential arsonist in every room.

Recently, I have started wondering how low will reimbursement have to go, how many hours per week, or how loud does the rhetoric have to get, before anesthesiologists decide that doing thier own cases is preferable to their current medical direction/supervision model. As physician salaries decline, the gap between CRNA and MD earnings gets smaller and smaller. Because of the unfair medicare part a passthrough advantage, NA's in rural america are already making close to or surpassing the starting salary for an academic anesthesiologist just finishing residency and in some cities a new graduate's salary for a group. For what I make currently, it's worth it to me to work like I do. Lately, I have really started thinking about what I would take just to be able to work 40 hrs per week, take care of one patient at a time (maybe two if I get called from recovery), manage the anesthetic my way, and not have to place my trust in someone who thinks that just because I am not in the room with them at that moment that I must be in the lounge drinking coffee or trading stocks. The more I think about what that number might be the closer it gets to what some NA's are making within 10 miles of my house.

In short, what happens when medical direction no longer makes sense?

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[cfdavid]

This is an interesting question. I'm curious to hear the opinions of other attendings on this matter.

 

[Gas]

I feel the same way - directing 4 nurses is not easy at times, especially with a ton of short cases. I feel pretty stretched at times, and if the law were to ever change where we can direct more than 4, that may be the straw that breaks the camel's back.

In short, if the gap in income continues to narrow, there will be a point where the increase in income is not worth the stress and hassle of directing multiple rooms. That point will be either having to direct more nurses to keep the current income level, or decreasing reimbursement combined with increasing nursing salaries, or some combination.

 

[24858]

Hi,
I am a recent grad and have been working in an all MD/DO group of about 10 of us. I love doing my own cases, knowing that what happens is on me and I dont have to run what I do or what plan I want to have happen by anyone else. It would be nice to have another set of hands during some of the tough airways I have come across, but I think I am quickly learning to become independent of directing people in the OR when I need an extra hand in an emergency.
I realize due to the number of anesthesiologists that we have that it is not realistic now to expect that all MD/DO could staff every OR. But it would be nice to have that. I feel that to leave this job and to go to a job where I supervise nurses would be a lesser job for ME. I love being the go to person in the delivery of my anesthetic and having to decide on my plan. Sure I will accomodate/listen to suggestions by the surgeon, but there is no third wheel that may disagree with me, no personal issues I have to deal with other than the anesthetic (ie, having to worry about hurting a nurses feelings if he/she doesnt agree with my plan or have to worry about that nurse following through on my plan).

 

[ProRealDoc]

Hi,
I am a recent grad and have been working in an all MD/DO group of about 10 of us. I love doing my own cases, knowing that what happens is on me and I dont have to run what I do or what plan I want to have happen by anyone else. It would be nice to have another set of hands during some of the tough airways I have come across, but I think I am quickly learning to become independent of directing people in the OR when I need an extra hand in an emergency.
I realize due to the number of anesthesiologists that we have that it is not realistic now to expect that all MD/DO could staff every OR. But it would be nice to have that. I feel that to leave this job and to go to a job where I supervise nurses would be a lesser job for ME. I love being the go to person in the delivery of my anesthetic and having to decide on my plan. Sure I will accomodate/listen to suggestions by the surgeon, but there is no third wheel that may disagree with me, no personal issues I have to deal with other than the anesthetic (ie, having to worry about hurting a nurses feelings if he/she doesnt agree with my plan or have to worry about that nurse following through on my plan).

This is the reason why I chose to go to a job where I will be doing my own cases. %$&^* supervision.

 

[pd4emergence]

This is the reason why I chose to go to a job where I will be doing my own cases. %$&^* supervision.

I wish that an MD/DO only practice would have been an option for me. There aren't any in my state and very few in this region. I have until now tolerated my situation because I feel my group does medical direction the right way and I am close to family. Lately, I've thought more and more about going to an MD only place. I am also seriously considering going back and doing a CC fellowship and staying in academics. I haven't quite decided what I am going to do other than the fact that by the end of next summer I won't be working here.

 

[sevo85288]

You need to get some like minded MD/DO's together in your area and form a group and go for contract. Be organized and well prepared to present why you are a better choice. Take a pay cut if you have to, it be well worth it. It can be done with the right people and attitude. MD/DO practice w/o nurses are the best. I love my job and can gave a great anesthetic to all my patients and am present from IV start to discharge. I call them the night before and the day after. They love it and it feels wonderful to take good care of people. Surgeons, nurses and administrators will also really appreciate it you as you are involved in the care of the patients. I go out of my way to offer to pain mgmt post op, help in the ICU with lines, and of course make sure the OR is running on schedule, smoothly. We go out of our way to uphold very high and professional standards. Again, you need young, energetic and like minded individuals in your area to get this started. Also, do not ever take a stipend from a hospital. Long term happiness is more important than short term gains.

 

[scudrunner]

On a related note, can anyone tell me which states are known to be mostly NA supervision practice states? I'm from MI and it seems to be heavy on the supervision here, but that's all I know. Any states with mostly physician only practices?

 

[nycitygas]

Most of new york city is MD only. I have heard New Jersey, Long Island is similar. Many VA hospitals are also MD only.
I am originally from the south and from I have heard, it seems primarily supervision although a resident from my program did get a job doing his own cases in Dallas.

 

[Mman]

Hi,
I love being the go to person in the delivery of my anesthetic and having to decide on my plan. Sure I will accomodate/listen to suggestions by the surgeon, but there is no third wheel that may disagree with me, no personal issues I have to deal with other than the anesthetic (ie, having to worry about hurting a nurses feelings if he/she doesnt agree with my plan or have to worry about that nurse following through on my plan).

I am supervising CRNAs and AAs all day and there is no disagreement with my plan. I'm in charge, it's my plan, and they work for me. If they don't like it, they know they can try to find another job somewhere else. They might not like it, but it's going to happen my way.

 

[24858]

Mman that sounds fab. Unfortunately from what I have heard from friends is that nurses may say they will follow your plan but once you leave it may be something else entirely. Also I am not sure how many young anesthesiologists would feel they have the clout to fire crna's or would even want to have to deal with that b.s. I certainly wouldn't want to even spend one once of my energy having to explain to a dept head why I felt a crna should be fired.

 

[Mman]

Mman that sounds fab. Unfortunately from what I have heard from friends is that nurses may say they will follow your plan but once you leave it may be something else entirely. Also I am not sure how many young anesthesiologists would feel they have the clout to fire crna's or would even want to have to deal with that b.s. I certainly wouldn't want to even spend one once of my energy having to explain to a dept head why I felt a crna should be fired.

Trust me, when you employ them it doesn't matter. The problem scenario is being in a group supervising when they are employees of the hospital and not you. Nobody blatantly ignores or disobeys orders without serious reprimand and/or loss of job.

 

[kmurp]

"Recently, I have started wondering how low will reimbursement have to go, how many hours per week, or how loud does the rhetoric have to get, before anesthesiologists decide that doing thier own cases is preferable to their current medical direction/supervision model."

To answer this part of your question: I would think that at a per location revenue of around $300,000 per location, the ACT model would break down given current CRNA compensation. At that point, one cannot afford both a CRNA and an MD to be assigned to one room even at a 1:4 ratio. One could, at that point, do supervision, all MD (if one could hire enough of them) or a mixture of solo MD and solo CRNA rooms.

 

[Mman]

"Recently, I have started wondering how low will reimbursement have to go, how many hours per week, or how loud does the rhetoric have to get, before anesthesiologists decide that doing thier own cases is preferable to their current medical direction/supervision model."

To answer this part of your question: I would think that at a per location revenue of around $300,000 per location, the ACT model would break down given current CRNA compensation. At that point, one cannot afford both a CRNA and an MD to be assigned to one room even at a 1:4 ratio. One could, at that point, do supervision, all MD (if one could hire enough of them) or a mixture of solo MD and solo CRNA rooms.

Part of the confusion in this is that there is not a set amount of revenue per location.

If you are MD only, you get reimbursed one amount.

If you are MD supervising CRNAs, you get reimbursed a different amount (less).

If you are MD supervising CRNAs that you directly employ, you get reimbursed a different amount (higher than if the hospital employs them).

It's all relative.

 

[pgg]

like being a fireman except with a potential arsonist in every room.

That is nicely put. Has a certain ring to it.

This is the way the military works. It's also the way my rural opt-out-state civilian moonlighting job works.

It describes my life pretty well. I do my own cases but I'm also the fireman, with a twist - no medical direction, no supervision. I am rarely involved in one of their cases until something goes wrong and the call for help goes out. Sometimes we're immediately available, sometimes we're in our own cases and can't help, sometimes the 'float' is across town at the surgicenter or in the other building doing preops, sometimes help is wearing a pager at home watching TV.

The interesting thing is that even if one of us is available, there's nothing that really obligates any of the anesthesiologists to respond to these crises ... but we still respond, mainly because we don't want the patient to die or suffer other harm. There would be no medicolegal consequences for us if we just ignored the call for help, but my employers (both the military and civilian group I work for) expect it and it's more or less a condition of employment.

I think this is the future. Anesthesiologist in room 1, CRNA in room 2, each doing his own cases. Scheduling person diligently screening cases and diverting the sick ones to the anesthesiologist ... and appeasing the surgeons who "get it" and ask for a physician for all cases. (Obviously this doesn't work well after hours.) Occasional 'curbsides' from CRNA to anesthesiologist. Occasional requests from CRNA to help out with an induction or airway. Occasional fires for which an anesthesiologist is (hopefully) available to rush in and help out. Occasional bad outcomes ... but probably not too often, because of case selection bias, and because the anesthesiologist safety net is still there, albeit with more gaps than a direction or supervision model.

This will probably be deemed "good enough" in an era of cost cutting. There is clearly substantially greater risk, but people seem willing to accept it.

 

[pd4emergence]

That is nicely put. Has a certain ring to it.

This is the way the military works. It's also the way my rural opt-out-state civilian moonlighting job works.

It describes my life pretty well. I do my own cases but I'm also the fireman, with a twist - no medical direction, no supervision. I am rarely involved in one of their cases until something goes wrong and the call for help goes out. Sometimes we're immediately available, sometimes we're in our own cases and can't help, sometimes the 'float' is across town at the surgicenter or in the other building doing preops, sometimes help is wearing a pager at home watching TV.

The interesting thing is that even if one of us is available, there's nothing that really obligates any of the anesthesiologists to respond to these crises ... but we still respond, mainly because we don't want the patient to die or suffer other harm. There would be no medicolegal consequences for us if we just ignored the call for help, but my employers (both the military and civilian group I work for) expect it and it's more or less a condition of employment.

I think this is the future. Anesthesiologist in room 1, CRNA in room 2, each doing his own cases. Scheduling person diligently screening cases and diverting the sick ones to the anesthesiologist ... and appeasing the surgeons who "get it" and ask for a physician for all cases. (Obviously this doesn't work well after hours.) Occasional 'curbsides' from CRNA to anesthesiologist. Occasional requests from CRNA to help out with an induction or airway. Occasional fires for which an anesthesiologist is (hopefully) available to rush in and help out. Occasional bad outcomes ... but probably not too often, because of case selection bias, and because the anesthesiologist safety net is still there, albeit with more gaps than a direction or supervision model.

This will probably be deemed "good enough" in an era of cost cutting. There is clearly substantially greater risk, but people seem willing to accept it.

Unfortunately, I think you are right. On a more positive note,I think that in this situation there could be a reemergence of MD only practices in areas that can recruit enough MD's to work there (ie nice places to live or good reimbursement areas). I do think the number of surgeons and patients requesting MD's for their cases would be a factor influencing this situation making hospitals more likely to hire MD's or an all MD group. Maybe a little direct competition for jobs would not be altogether a bad thing. Some CRNA's may say we can do anything you can do but when it comes down to a choice b/t the providers, most surgeons and patients are gonna pick an MD if they can.

 

[cfdavid]

Unfortunately, I think you are right. On a more positive note,I think that in this situation there could be a reemergence of MD only practices in areas that can recruit enough MD's to work there (ie nice places to live or good reimbursement areas). I do think the number of surgeons and patients requesting MD's for their cases would be a factor influencing this situation making hospitals more likely to hire MD's or an all MD group. Maybe a little direct competition for jobs would not be altogether a bad thing. Some CRNA's may say we can do anything you can do but when it comes down to a choice b/t the providers, most surgeons and patients are gonna pick an MD if they can.

Indeed. If the AANA ever really got it's wish, it would be a serious problem for them, it seems to me.

 

[scudrunner]

That is nicely put. Has a certain ring to it.

This is the way the military works. It's also the way my rural opt-out-state civilian moonlighting job works.

It describes my life pretty well. I do my own cases but I'm also the fireman, with a twist - no medical direction, no supervision. I am rarely involved in one of their cases until something goes wrong and the call for help goes out. Sometimes we're immediately available, sometimes we're in our own cases and can't help, sometimes the 'float' is across town at the surgicenter or in the other building doing preops, sometimes help is wearing a pager at home watching TV.

The interesting thing is that even if one of us is available, there's nothing that really obligates any of the anesthesiologists to respond to these crises ... but we still respond, mainly because we don't want the patient to die or suffer other harm. There would be no medicolegal consequences for us if we just ignored the call for help, but my employers (both the military and civilian group I work for) expect it and it's more or less a condition of employment.

I think this is the future. Anesthesiologist in room 1, CRNA in room 2, each doing his own cases. Scheduling person diligently screening cases and diverting the sick ones to the anesthesiologist ... and appeasing the surgeons who "get it" and ask for a physician for all cases. (Obviously this doesn't work well after hours.) Occasional 'curbsides' from CRNA to anesthesiologist. Occasional requests from CRNA to help out with an induction or airway. Occasional fires for which an anesthesiologist is (hopefully) available to rush in and help out. Occasional bad outcomes ... but probably not too often, because of case selection bias, and because the anesthesiologist safety net is still there, albeit with more gaps than a direction or supervision model.

This will probably be deemed "good enough" in an era of cost cutting. There is clearly substantially greater risk, but people seem willing to accept it.

I think that every anesthesiologist in this position should document every call for help by independent NAs, what went wrong, why it went wrong, and how it was resolved. The documentation could be something like access to a website- just fill out a questionnaire and submit it. Then, after one year, collect and analyze all of the data and publish the results. It would be enlightening, to say the least.

Why is this not being done? It's an ace in the hole.

 

[rsgillmd]

I think that every anesthesiologist in this position should document every call for help by independent NAs, what went wrong, why it went wrong, and how it was resolved. The documentation could be something like access to a website- just fill out a questionnaire and submit it. Then, after one year, collect and analyze all of the data and publish the results. It would be enlightening, to say the least.

Why is this not being done? It's an ace in the hole.

Probably because to able to verify such incidents actually took place would risk exposure of private information of patients. I doubt very many patients would be willing to consent. Otherwise the argument would be that a bunch of radical MDs made up reports of incidents that didn't occur.

 

[bibibi]

I think that every anesthesiologist in this position should document every call for help by independent NAs, what went wrong, why it went wrong, and how it was resolved. The documentation could be something like access to a website- just fill out a questionnaire and submit it. Then, after one year, collect and analyze all of the data and publish the results. It would be enlightening, to say the least.

Why is this not being done? It's an ace in the hole.

Hm.... Maybe the same should be done for MDs consulting other MDs or working collaboratively on a difficult case? Then you can say MDs cannot work independently and should practice in groups (which is nonsense). What is wrong with collaboration? If something went wrong or a case is difficult the most important thing is patient's life. Let's forget about titles and do our jobs to ensure best patient outcomes.

 

[pd4emergence]

I think that every anesthesiologist in this position should document every call for help by independent NAs, what went wrong, why it went wrong, and how it was resolved. The documentation could be something like access to a website- just fill out a questionnaire and submit it. Then, after one year, collect and analyze all of the data and publish the results. It would be enlightening, to say the least.

Why is this not being done? It's an ace in the hole.

I know what you are getting at here. The APSF is actually working on a current up to date data base for critical incidents in anesthetic cases. Unfortunately, they are relying on AIMS systems for their data. Most places with an AIMS (computerized anesthetic record) system are going to be bigger academic or private institutions that have residents, employ an ACT model or MD only model. This if it can get off the ground, will be a win for patient safety. I really think that every OR mishap or critical incident should be reviewed and disected down to the last detail. This is what happens in aviation. When was the last major commercial aviation accident with a fatality? None in 2010. As for what happens in podunkville, independent NA's will probably go on reporting only wins ("the patient didn't die in the OR right?") especially to CMS.

Unfortunately, there really is no way to compare providers except in a prospective study. This will probably never happen. Maybe if enough of the "CRNA's are a cheaper, better, more caring alternative to MD's" crowd would put their money where their mouth is and sign up for the non MD group there would be enough participants. But given the choice, they may wisper in your ear that they don't want to be in that group either.

 

[scudrunner]

Hm.... Maybe the same should be done for MDs consulting other MDs or working collaboratively on a difficult case? Then you can say MDs cannot work independently and should practice in groups (which is nonsense). What is wrong with collaboration? If something went wrong or a case is difficult the most important thing is patient's life. Let's forget about titles and do our jobs to ensure best patient outcomes.

You are missing the point. I'm not saying there is anything wrong with collaboration, I'm saying a physician is justifiably the best person for a NA or a fellow MD to turn to when **** hits the fan.

The fact that needs to be proven is that NAs, especially NAs practicing independently in the same setting as an MD, require MD bailout a whole lot more than they are willing to admit (and exponentially more than a fellow MD would need).

What we're really talking about is proving a confounding factor in NA safety outcomes. The AANA touts equal safety when NAs practice independently, but they ignore the fact that in many situations the good outcome was achieved because a physician was available to help. That is the confounding factor. Exposing this would justify the need to retain an ACT model and physician supervision, squashing the AANAs heedless push for independence.

Like you said, ensuring the best patient outcome is of the utmost importance, that is why we need to ensure appropriate physician involvement in every case.

 

[countingdays]

You are missing the point. I'm not saying there is anything wrong with collaboration, I'm saying a physician is justifiably the best person for a NA or a fellow MD to turn to when **** hits the fan.

The fact that needs to be proven is that NAs, especially NAs practicing independently in the same setting as an MD, require MD bailout a whole lot more than they are willing to admit (and exponentially more than a fellow MD would need).

What we're really talking about is proving a confounding factor in NA safety outcomes. The AANA touts equal safety when NAs practice independently, but they ignore the fact that in many situations the good outcome was achieved because a physician was available to help. That is the confounding factor. Exposing this would justify the need to retain an ACT model and physician supervision, squashing the AANAs heedless push for independence.

Like you said, ensuring the best patient outcome is of the utmost importance, that is why we need to ensure appropriate physician involvement in every case.

Collaboration implies help in both directions. One-sided collaboration is called supervision.

 

[ctsicu]

Hm.... Maybe the same should be done for MDs consulting other MDs or working collaboratively on a difficult case? Then you can say MDs cannot work independently and should practice in groups (which is nonsense). What is wrong with collaboration? If something went wrong or a case is difficult the most important thing is patient's life. Let's forget about titles and do our jobs to ensure best patient outcomes.

whatever, murse troll!!!!!! MDs only call each other when there's a real situation, not when there's an incompetent screw up in murse land.