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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.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.
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.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.
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.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.
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.
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.)Our boss (IM head) espouses the philosophy that everyone should practice to the top of their license.
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. . . )
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?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.
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.
There are many MDs who haven't done blocks in yearsYes. 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.
Do you know that physicians represent only 8% of healthcare expenses? American healthcare is expensive especially because of (in random order):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.
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.
For now. I don't see it getting any better in the future.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.
There are many MDs who haven't done blocks in years
For now. I don't see it getting any better in the future.
It is a bad idea; it happened because of CRNA lobbying; CRNAs are opposed to changing that rule.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.
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 can't see a reason why a CRNA would lobby against an AA except because it hurts their salaries.
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.
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 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.
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.
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.
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.
government never gets "a little" involvedthe 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.
Well, that is a problem, I don't deny it. I just don't know how to fix it.government never gets "a little" involved
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.