Michigan CRNA's set up Go Fund Me page to raise money for lawyers!

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Clearly I have touched a nerve here.

You know that I don't think MDs and APPs are equivalent.

But a better trained midlevel is better for patient care. That includes having the humility that Man O War referenced when referring cases beyond one's level of competence.

But if the options are nobody or a well trained APP, I'll take the APP.
In these modern times, there is nothing preventing remote physician oversight of a midlevel in a rural/underserved scenario for office visits. And of course that would be very similar to an ACT model.
 
I don't understand why well trained APPs are such a threat to you.

Yes we train APPs in oncology because it increases access.

They don't get paid as much as physicians, and neither do CRNAs.

A well trained APP improves care all around.
First off, you are contradicting yourself. You have already stated that a solo MD=solo CRNAs in one of your previous posts as far as hierarchy.
Are your APPs practicing independently? And if they are are they getting paid the same as your partners?
Medicare pays the same for CRNA or physician care. I believe private insurers vary in their reimbursement if care is provided by nurses or docs.
And if a doc wants to go rural and bill for themselves they should. But if they are getting a salary they should not get paid the same as a CRNA. Why? One, knowledge base, and decision making. Two, most CRNAs demand and get paid overtime. So therefore they make a lot more money from overtime pay. How many docs do you know besides locums get paid for overtime?

When they say that they are cheaper, they are not necessarily telling the truth if they are getting overtime pay or if they are billing independently. That is just used to trick the public. Plenty of them in rural America are making 300 to 400k. Same as many docs. But some of their income gets subsidized by the government. Rural pass thru and all that.
 
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If he wants the mid level to assume his entire case then I have a problem.

But the better trained the midlevel, the more access there is to care.
So, independent midlevels aren't appropriate. The only difference between your statement for your field and that of the anesthesiologist is domain knowledge of the respective fields.

The logic of the argument for midlevel independence should not be speciality specific.
 
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Wow - this back and forth with Aralc (or is it Clara?) has been interesting - you seem to be all over the place - having just joined the SDN community and the Anesthesiology forum of all places and you are all over the Crains articles as well. I'm wondering what skin you really do have in the game here with the CRNAs?

As for this discussion and the topic at hand here - I will tell you all (not that most of you reading this don't already know) that there are a lot of other differences to the physician only delivered anesthesia vs CRNAs - now that we are two weeks into this at the hospital the surgeons at the hospital have all taken note of our presence. The silver lining in all of this for us has been that our entire group in less than two weeks time have proven to the hospital, the surgeons, the rest of the OR staff our value and the need for our presence. PSJ and Dr. Lago have not "caved" nor are we looking for the other side to "cave" - that word choice creates an animosity that we don't want should some of the CRNAs opt to return to work alongside us in the ACT model.
 
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Aralc, if you have a problem with your patient getting all his or her care from a mid level, why would you encourage anesthesiologists to train middle levels and let them be solo?

Read Copacetic Ones last line above.
 
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Aralc, if you have a problem with your patient getting all his or her care from a mid level, why would you encourage anesthesiologists to train middle levels and let them be solo?

Read Copacetic Ones last line above.

The point that I am trying to make, which doesn't seem to be getting across, is that a well-trained mid-level is also an asset.

They are not a threat to either a patient or the physician. They are good for both. A well-trained mid-level will improve access to care for the patient and actually also generally increases the physician's salary.

I think that if physicians don't embrace this, it is detrimental in many ways, not the least of which by creating an atmosphere of antagonism between two providers who should be working together for the best interest of the patient and the public.
 
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Our boss (IM head) espouses the philosophy that everyone should practice to the top of their license.
That's a very dangerous idea, promoted by greedy corporate types. Where is the top of the license? It differs for every individual, so we should not have general rules. (Just the other day I was telling a colleague how stupid it is that training has the same length for everybody, while it should be like a PhD. One should finish residency or fellowship whenever one is competent enough to practice independently. E.g. IM residency could be 2 years for some and 5 for others.)

I agree that everyone should practice to the maximum of their competence, as long as competence does not mean good enough, but almost excellence. Medicine is not a place for the Pareto or Peter principles. One should not cut corners, because mistakes affect people's lives. We should all do only things we are very good at, or things that have little impact on the patient if we make a mistake. Fake it till you make it is OK when selling shoes, but not for medicine.

So while an APRN might be good enough to treat a cold, for example, an APRN should not diagnose or treat 80% of patients independently, because s/he lacks the excellence part. If the patient is one of the 10-20% where things are not what they seem, there is a very good chance s/he'll miss it. The problem is that one cannot predict which new patients will be complicated and triage patients accordingly, except in some procedural specialties, such as anesthesia.

First, do no harm. Second, do no harm. Third, do no harm. Misdiagnosis is harm. Mistreatment is harm.

The solution for rising healthcare expenses is not less competent providers. It's empowering doctors to say no to futile care and eliminating the need for defensive medicine.
 
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The point that I am trying to make, which doesn't seem to be getting across, is that a well-trained mid-level is also an asset.

They are not a threat to either a patient or the physician. They are good for both. A well-trained mid-level will improve access to care for the patient and actually also generally increases the physician's salary.

I think that if physicians don't embrace this, it is detrimental in many ways, not the least of which by creating an atmosphere of antagonism between two providers who should be working together for the best interest of the patient and the public.

Here is an example of a truly appalling statistic that I found out a while ago - a significant number of men with advanced prostate cancer will get absolutely horrific care by not being offered a simple treatment/procedure that is 90% effective and will likely extend life by years. The level of decision-making here is not complex.

If I thought that training independent oncology APPs would fix that problem, I would do it in a heartbeat. (actually, maybe that is not a bad idea. . . )

Ok, I see where we are not "meshing" as far as thought processes here concerning mid levels. Since this is the internet and tones can be misconstrued I'll start by saying I'm not meaning this to talk down or be condescending at all....the difference between oncology and anesthesiology is major, which is why you can't compare the way mid levels are used (NOT saying one is superior to the other, just that they're different). I don't practice oncology obviously, but when a mid level sees a patient, he/she has the luxury of time to consult with you on the proper course of treatment, and before that treatment course begins. Meaning if they devise a plan that is bad, there is a physician there to correct that before it affects the patient negatively. I liken this to the supervision model that so many docs advocate for. In oncology, there are not mid levels totally independent of oncologists out there treating patients on the scale that CRNAs currently are, and you've already stated that you would have a problem with that so why wouldn't anesthesiologists who see day in and day out the clinical skills of mid level providers. In anesthesia, complications can happen fast and furious, and if the provider does not have adequate training to make good decisions on the fly or they simply haven't seen enough of the complication to effectively treat it so the patient doesn't die or become brain dead, bad things happen fast. So yes, CRNAs unsupervised can be a huge threat to a patient if not properly supervised. The antagonism exists because of their constant push for independence. There is also an equivalent mid level to a CRNA called Anesthesiologist Assistants. They do the exact same job, but the difference is they don't push for independence and seek to work in a collaborative model with docs. There is no antagonism between anesthesiologists and AAs for that reason.
To your other point again because of the IM vs procedural nature of the respective specialties, there isn't a way to remotely collaborate with CRNAs to increase rural access safely and competently. I honestly don't have an answer for that issue because I don't know what would happen if the pass through money were given to either docs or CRNAs, but I would bet that they could utilize that money to attract physicians just as they attract CRNAs. It makes no sense to me that the pass through money can only be used for mid level providers. Some folks might argue that many service lines shouldn't be performed in rural hospitals due to abysmal outcomes, which would lessen the number of anesthesia providers required.
 
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Yes to this. Level the playing field. If the CRNAs object to that, it clearly suggests that their motive is financial and not for patient safety.
But I think what will end up happening if the same money is available to both, you may still end up with a CRNA because they will work for less or MDs will still choose the lucrative jobs in more desirable areas. It is my opinion that your field really needs well trained APPs.

We have them, they're called AAs and the CRNAs actively rally against them because they don't want the competition from a provider who wants to work collaboratively with the docs vs independently.
 
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Yes to this. Level the playing field. If the CRNAs object to that, it clearly suggests that their motive is financial and not for patient safety.
But I think what will end up happening if the same money is available to both, you may still end up with a CRNA because they will work for less or MDs will still choose the lucrative jobs in more desirable areas. It is my opinion that your field really needs well trained APPs.
Are you familiar with pass-through legislation as it pertains to anesthesia care in rural areas?
 
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Another option would be to increase the number of anesthesia residents so that all hospitals could have MDs, thus driving down MD salaries.

Don't see that happening either.

The law does not permit this. There is better reimbursement for rural critical access hospitals to employ CRNAs. This is how the law is written.
 
Aralc, my feeling is that, in the last few decades, many American nurses, especially APRNs, have been brainwashed into thinking that physicians are just some useless legally-required "appendages" of the patient care "team". They think we could be replaced by a good knowledge base, such as Uptodate, and some good protocols. (And we can, for the young healthy straightforward predictable easy patients.)

There is a strong component of feminism mixed with class warfare and intellectual inferiority complexes, that seems to circulate in nursing circles in the last couple decades. Meaning that many young nurses graduate school with the misconception that the main reason they are not allowed to do certain things is because the big bad (male) doctors don't want to let them practice "at the top of their license", because they want to keep them in the centuries-old (female) servitude. Especially if they have advanced degrees, since one can learn in APRN/CRNA/DNP school what others learn in medical school, one could buy and read the same books, one could take care of patients the same way etc. Or at least that's what they are brainwashed into.

So expecting these people to just admit that they are less competent than physicians is wishful thinking.
 
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Yes. My thing is how can you say you're ready for independent practice when you don't competently (or don't at all) place central lines and don't do nerve blocks (the majority of CRNAs/AAs I've personally known)? They don't advocate for some to have independence, they advocate for all to have independence. I think the difference between anesthesiologists and CRNAs is docs admit to their limitations. Sick peds, pain procedures, etc without specialized training. Those are better left to anesthesiologists who took the time and did the training.
There are many MDs who haven't done blocks in years
 
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The only problem is that (I don't think) there are enough doctors to deliver the "best" care to every single person in America. The question then becomes how to best provide care given limited resources (and even though we live in a very wealthy country and spend a ridiculous amount on health care, there are still limited resources). I think we need to maximize the clinical competence of every single health care provider, including APPs.
Do you know that physicians represent only 8% of healthcare expenses? American healthcare is expensive especially because of (in random order):
- the need for defensive medicine, and lack of tort reform and specialized medical courts
- the rampant futile or expensive care on somebody else's money
- the delusion that healthcare is a right
- medical and pharmaceutical patents for even the most laughable things
- a ton of nonproductive middle men, such as insurance companies, or managers and executives in hospitals.

If we were to make cuts in a rational, fact-based manner, doctors should be among the least of our concerns. The fact that we are being singled out speaks volumes about our public image and lack of political and workplace power.
 
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Aralc, my feeling is that, in the last few decades, many American nurses, especially APRNs, have been brainwashed into thinking that physicians are just some useless legally-required "appendages" of the patient care "team". They think we could be replaced by a good knowledge base, such as Uptodate, and some good protocols. (And we can, for the young healthy straightforward predictable easy patients.)

There is a strong component of feminism mixed with class warfare and intellectual inferiority complexes, that seems to circulate in nursing circles in the last couple decades. Meaning that many young nurses graduate school with the misconception that the main reason they are not allowed to do certain things is because the big bad (male) doctors don't want to let them practice "at the top of their license", because they want to keep them in the centuries-old (female) servitude. Especially if they have advanced degrees, since one can learn in APRN/CRNA/DNP school what others learn in medical school, one could buy and read the same books, one could take care of patients the same way etc. Or at least that's what they are brainwashed into.

So expecting these people to just admit that they are less competent than physicians is wishful thinking.

I don't disagree that there is a large amount of propaganda out there. I just believe that reality is the best teacher. I don't think anyone who knows anything would pay a newly minted CRNA the same as a newly minted anesthesia attending. Which means that the people who really matter can see the truth.
 
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I don't disagree that there is a large amount of propaganda out there. I just believe that reality is the best teacher. I don't think anyone who knows anything would pay a newly minted CRNA the same as a newly minted anesthesia attending. Which means that the people who really matter can see the truth.
For now. I don't see it getting any better in the future.

The genie got out of the bottle when nursing boards stopped being supervised by medical boards. Since then, there has been a continuous effort to undermine the difference between a physician and a nurse.
 
There are many MDs who haven't done blocks in years

Take a random sample of 100 docs and a random sample of 100 CRNAs and compare block numbers/block proficiency if you want to be fair about that.
 
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No. Midlevels only increase greedy owner profits, not our salaries. Supervising midlevels to a ratio where it makes financial sense (1:3 or higher in anesthesia) equals worse care.

There are no midlevels in many other developed countries, and still they have better and cheaper healthcare. There is no need to replace/extend physicians with midlevels, except in a race for profits at any price.
 
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For now. I don't see it getting any better in the future.

I guess. But money (and life/death) is a significant motivator for people to figure out the truth.
 
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The problem is that the train has left that station a decade ago or more. Nowadays we make less money in medicine, inflation-adjusted, than working solo 10-20 years ago, despite supervising our butts off, despite the cost of healthcare going up. Why? Because all the other problems I mentioned have only become worse.

And yes, I have always taken a smaller salary in exchange for being able to provide better care. I don't plead for 1:2 supervised anesthesia care; I plead for solo physician care. Plus I don't believe in "team" care where one person assumes the malpractice risks for the entire team.
 
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I think you are referring to the fact that CRNAs are actually advantaged to providing anesthesia care in rural areas. This seems like a bad idea to me, not sure how that happened. And what I was trying to say that is if CRNAs are opposed to changing that rule, it goes to motives.
It is a bad idea; it happened because of CRNA lobbying; CRNAs are opposed to changing that rule.

I can't see a reason why a CRNA would lobby against an AA except because it hurts their salaries.
CRNAs do lobby against AAs. They fight tooth and nail in every state where legislation to permit AAs to practice is introduced. The incredulous irony of it is that their argument is that AAs' training and education is inferior to their own.


I hope you're beginning to catch a glimpse of the edges of the problem?

Because this problem is coming to your world, too, sooner or later. There isn't a "level playing field" and there isn't a concern for patient care, or safety, or honesty. There is just money. And from the legislature's perspective, a dollar from their lobbyists spends just as nice as any other ...
 
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docs are not being singled out. expensive care is being rationed, to the point of making my job almost intolerable. The only reason I put up with it (including the increase in my health care premiums) is because I know that rational rationing is critical to the survival of American health care.

How do you feel about irrational rationing?
 
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docs are not being singled out. expensive care is being rationed, to the point of making my job almost intolerable. The only reason I put up with it (including the increase in my health care premiums) is because I know that rational rationing is critical to the survival of American health care.

rationing is not critical american health care, the end of attempting to centrally manage the field is the solution
 
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how do you see that playing out? Should we get rid of all claims to malpractice? Licensure? FDA approvals? Insurance?

Colleague of mine was advocating for a concierge hospital,where everything was private pay. I saw his point in principle, but in practice didn't know how that model was going to work.

Well, if you can honestly show me how a completely unregulated health care industry will function effectively and safely, I will be glad to say I am wrong.

Problem with hospitals is they have enforced monopolies via the demonstrated need rules and they don't get to demand payment due to emtala. I don't actually think we need licensure via government because as I mentioned before, the patient is the one who should be held responsible for which provider they want. In a true market system, you would see what people are actually willing to pay for services. The trick is, so many people are used to not actually paying that it would never last an election cycle...making other people buy you things is too popular
 
the problem is, human nature everywhere is corrupt. But believing that it is only corrupt can't be a healthy way to live your life.

We need more people like Salerme.
 
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So we agree.

But look at FFP's argument about safety and cost-effectiveness.
Is it really true that the only safe way to provide anesthesia is either 1:2 or solo physician? Then why do physicians lobby for AAs? What is the benefit of the AA?

The AA (as far as I know) can't go to a rural independent practice. So again, goes to motives.

Keep the interest of the public and the patient first and it will all settle down. Work together for the better good.

Benefit of the AA in
drives me crazy.

Like CRNAs getting paid more for being in rural areas than an MD, CRNAs lobbying against AAs, and physicians lobbying against an independent CRNA in an underserved area. and physicians saying that solo physician anesthesia is the only safe way to deliver it while at the same time supporting AAs.
And CRNAs demanding to get paid the same as an MD or abusive scheduling for their own benefit. There is a lot of stupid stuff that happens because we can't look past our own self-interests.

A bone for the intensivist - a family insisting that their family member be kept alive in the unit for MONTHS AND MONTHS because they were collecting some type of benefit.

I think it's too simplistic to say the safest way to deliver anesthetics is _____. It really depends on the type of procedure/case.
 
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Benefit of the AA in my experience working with them in the past (I currently do my own cases, so don't supervise now)- less attitude, more collaborative approach to patient care. Imagine telling one of your APPs to do something and they didn't do it, because they wanted to treat the patient the way they saw fit, even though they're working under your license.


I think it's too simplistic to say the safest way to deliver anesthetics is _____. It really depends on the type of procedure/case.

I agree with everything you said here. Except the implication that a CRNA can't work well with an MD
 
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the other trick is that there are unscrupulous folks on the provider side willing and able to con patients, such as Dr. Fata, Michigan oncologist who decided to give chemotherapy to patients without cancer in order to line his own pockets. Disgusting. I am willing to accept a little government involvement if it can prevent such a tragedy, or if justice for those families can be served.

I am also willing to pay (reasonably) more in insurance premiums if helps my inner-city patient get life-prolonging treatment. My kids' vaccinations are about 3-5x what it costs if we went to the health department. Maybe more. I figure I am subsidizing somebody else's kids getting vaccinated.

the problem is, human nature everywhere is corrupt. But believing that it is only corrupt can't be a healthy way to live your life.

We need more people like Salerme.
government never gets "a little" involved
 
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government never gets "a little" involved
Well, that is a problem, I don't deny it. I just don't know how to fix it.

I think that the problem is that anytime you set up the system a certain way, one group or another will try to use it for their advantage. So you just end up having to pile rule upon rule upon rule to make people do the right thing, when we should all just be doing it on our own.
 
So they are having "talks?" Is there any way the hospital is going to give the CRNAs their jobs back after they attacked the hospital and their supervising physicians? Are the anesthesiologist going to supervise them? I wouldn't want anything to do with people who said I couldn't turn on a machine or I'm an overpaid babysitter. The tension at work would be too thick.
 
There has got to be a better way to create a distinction between the 2 without being demeaning, offensive or fear mongering the public. I valued the knowledge base of the docs from the group I started in. They were all excellent clinicians, cared about the patients, I trusted them implicitly because they were great and had my back. I leaned on them for their knowledge base in those situations I just didn't have the background to draw from. They also though took the time to teach when needed, praise when appropriate and never acted like doing so was a threat to their livelihood. We in turn embraced the opportunities they gave us and were thankful they valued us. e.

I'm sorry if my words and actions seemed disrespectful to your profession. I have mad respect for what you do. I just want to live in the world that Sarleme describes here. Where excellence in clinical care is valued by all and in all, putting the patient and integrity first at all times, and putting down our egos.

I know we all do it, every time we ask for help from a colleague, every time we invest effort into advancing our clinical skills, every time we endure a hardship because we think it is in the patient's best interest.

Please take that as a humble entreaty to work towards the cordial and collegial relations that seidnarb stated were the norm in his workplace.

My oncology nurse saved my patient's life running his code after a chemo reaction because she was in the room with him. I am entirely indebted to her and know that my team is stronger because of her clinical excellence. It is not a zero sum game.
 
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The only way there is true peace and collaboration, when working with CRNAs, is if they are employed by the respective anesthesiologists. Probably this applies to other specialties, as well. Nobody bites or debates the hand that feeds him/her, even the militant kind.

An environment where CRNAs and anesthesiologists are both employees is dangerous, unless there are serious consequences for insubordination (which means at least having the same employer). Not to mention the situation in which the midlevels own the group and employ the anesthesiologist.
 
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