Midlevels doing surgery solo

Taurus

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    So I was in the OR today talking to the anesthesia resident. She was telling me that she had a patient who came in because of post-LP headache and needed a blood patch. The patient said that a CRNA at an outside hospital in Geauga, OH had done the epidural. On speaking with the CRNA, the resident finds out that midlevels at this hospital are not only during epidurals without any supervision whatsoever but they're also doing some surgeries such as lap appy's without supervision. When did we start allowing midlevels to do surgery solo?
     

    ESU_MD

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      Don't take this the wrong way.... but

      at some places, esp those without anesthesia residents, you would rather have the CRNA's doing your case than the gas doc.

      as far as solo surgery- its not a big deal for a PA to drop the trocars in solo, or dry up and close. in fact it happens all the time.

      Isn't that the american dream? Be in private practice, have a PA closing in 1 room, while another PA is opening in the next? Ideally, with a nurse practitioner taking floor calls and doing the dictations!
       

      dynx

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        Don't take this the wrong way.... but

        at some places, esp those without anesthesia residents, you would rather have the CRNA's doing your case than the gas doc.

        as far as solo surgery- its not a big deal for a PA to drop the trocars in solo, or dry up and close. in fact it happens all the time.

        Isn't that the american dream? Be in private practice, have a PA closing in 1 room, while another PA is opening in the next? Ideally, with a nurse practitioner taking floor calls and doing the dictations!

        Ugh. Yeah, thats great for the older surgeon, helps him make a lot more money. Just like riding the Gravy train to excess during the 80s. The future generation? F*ck em. Them kids gotta 80 hour work week. Wimps.
         
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        Southpaw

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          Don't take this the wrong way.... but

          at some places, esp those without anesthesia residents, you would rather have the CRNA's doing your case than the gas doc.

          as far as solo surgery- its not a big deal for a PA to drop the trocars in solo, or dry up and close. in fact it happens all the time.

          Isn't that the american dream? Be in private practice, have a PA closing in 1 room, while another PA is opening in the next? Ideally, with a nurse practitioner taking floor calls and doing the dictations!

          What you describe is pure greed, which I guess in many minds describes the American dream. The result of this is what we see today, NPs and PAs seeking more and more autonomy, without physicians (aka the AMA) bringing in the reigns. If nothing is eventually done, I see NPs and PAs competing for our residency slots. Funny thing is, on an individual basis, most docs don't give a crap as long as they get theirs. Of course, that mindset is ridiculously selfish, but docs have a reputation for leaving the problems of medicine for the next generation to deal with.
           

          Castro Viejo

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            Of course, that mindset is ridiculously selfish, but docs have a reputation for leaving the problems of medicine for the next generation to deal with.

            That's the boomer generation for you. And when a boomer becomes a physician? Man, "raping and pillaging" the profession don't even cut it.

            Thanks mom and dad.
             

            Castro Viejo

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              On speaking with the CRNA, the resident finds out that midlevels at this hospital are not only during epidurals without any supervision whatsoever but they're also doing some surgeries such as lap appy's without supervision. When did we start allowing midlevels to do surgery solo?

              Are you talking about putting the trocars in or actually doing the dissection, stapling off the appendix, and essentially doing the case?

              If it's the former that happens in most private practice/community hospital settings. Our CV service has PAs opening and closing the chest, harvesting the vein, etc. If it's the latter, then that's something I've heard of, read stuff about on the internet, but I've never seen it in real life nor do I really believe it exists.

              Kind of like the female orgasm.
               

              Winged Scapula

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                When supervising a midlevel with OR privileges, the attending physician must be present for the "critical" portion of the procedure. What that entails varies, but most would agree that for a lap appy it would include the dissection and stapling off.

                How you define being "present" varies as well but if the midlevel is doing the above without the attending in the room, I'd venture most hospitals would frown upon that.

                Putting in the trocars, closing the wounds, etc.? Pretty common place, especially in community practices and in some cases, no different than what the resident is allowed to do.

                That being said, I find it a bit distasteful to be billing patients for procedures you aren't doing. Older surgeons have no one to blame but themselves when it comes to midlevels getting more and more power.

                Finally, I'd be careful about what rumors you spread as generated by an anesthesia resident. Many do not understand the procedures and she may be interpreting "doing the case" as putting in the trocars, looking around and finding the appendix, and closing the wounds. There's a little more to it than that.
                 

                Chronic Student

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                  Just to throw in my .02.

                  I've seen my fellow PAs do a lot of things, but I have yet to see even 1 of them do the "critical" part of the procedure.

                  In addition, it is hard for me to believe that a hospital would credential them to do that, that their malpractice insurance company would let them do that and lastly that they will have more than a cardboard box left to their name when there is a serious complication (and we all know it will eventually happen) during the time in the OR when the doc is not physically in the room.

                  I must admit I have done a few very small operations (read burrholes) skin to skin, but my boss was right next to me. I cannot imagine him even asking me to do an operation alone (even something as simple as burrholes) much less me actually saying yes to it.
                   

                  supercut

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                    Don't take this the wrong way.... but


                    as far as solo surgery- its not a big deal for a PA to drop the trocars in solo, or dry up and close. in fact it happens all the time.

                    Funny how in my (northeast) surgical program, a surgery resident wasn't allowed to start a case (hell, they aren't even allowed to particpate in the 'time out'..had to be the attending) until the attending is in the room. Well, technically a chief was allowed to start a case independently, but on more than one occasion the OR staff refused to allow that to happen, even for stuff like lap appys. But it's "no big deal" for a PA to drop trochars without the attending. What happens when there's a trocar injury...caused by the PA?
                     

                    Winged Scapula

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                      They're not the ones complaining about it.

                      They're the ones telling everyone to "suck it up" and "quit whining". Easy to say when you're making a buck off my future practice opportunities.

                      As part of my history on patients with hip fractures, I will be asking, "Are you a physician, and if so, have you ever employed an NP or CRNA?" If the answer's yes, you get shortened by 3cm. Welcome to shoe-lift hell, you bastard.
                      :laugh:

                      I guess what I meant to say is that we all realize that its the older surgeons who sold out the field and when they try to pin the blame on someone else, it ain't washing with me.

                      These are the same guys who whine about the 80 hr work week - they have no one to blame but themselves for the problems.
                       

                      dynx

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                        :laugh:

                        I guess what I meant to say is that we all realize that its the older surgeons who sold out the field and when they try to pin the blame on someone else, it ain't washing with me.

                        These are the same guys who whine about the 80 hr work week - they have no one to blame but themselves for the problems.

                        Whats gonna be nice is, as tired mentioned, when these fools start hitting the age where thier gonna need some serious cutting done on them...Who's gonna do it? The residents they sell out? The guys they screw so they can make an extra buck? Can't find an NP do do a whipple on you eh? To bad you couldn't take the time and expense to protect your career so that the best and brightest keep going into real surgery fields.
                         

                        opr8n

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                          here is another Q
                          at your program who does ICP bolts?
                          NS resident, NS attending, Trauma resident, Trauma attending?
                          Are residents allowed to do them without supervision?

                          i ask b/c at our program the NS attending sdont want to do them
                          and we dont have NS residents
                          so the trauma residents put them in
                          but if thats the case
                          do you need supervision for that procedure??
                           
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                          Winged Scapula

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                            here is another Q
                            at your program who does ICP bolts?
                            NS resident, NS attending, Trauma resident, Trauma attending?
                            Are residents allowed to do them without supervision?

                            i ask b/c at our program the NS attending sdont want to do them
                            and we dont have NS residents
                            so the trauma residents put them in
                            but if thats the case
                            do you need supervision for that procedure??

                            At my residency program, the Nsgy residents put them in.

                            I have put one in myself when I asked a Nsgy resident if they would show me how. No attending supervision in either case...senior Nsgy residents show the juniors, and so on.
                             

                            Castro Viejo

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                              here is another Q
                              at your program who does ICP bolts?
                              NS resident, NS attending, Trauma resident, Trauma attending?
                              Are residents allowed to do them without supervision?

                              Yes, yes, yes, and yes. Even the occasional fly-by-night "Neurosurgical PA" that we have covering from time to time will put a bolt in.

                              The level of supervision needed depends on who's putting it in. The juniors who are "privileged" don't need to be supervised at all.
                               

                              ESU_MD

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                                The level of supervision needed depends on who's putting it in. The juniors who are "privileged" don't need to be supervised at all.

                                As a rule of thumb, I don't like to do procedures that I can't handle the complications of- like ICP monitors.
                                99% of the time they go right in, but the 1% that you get into bleeding or whatever, its just not worth it. then you have to call someone to bail you out of a procedure you shouldnt have done in the first place.

                                Kinda like how surgeons feel when the gi guys perf someone, or the idiot cards guys get a hematoma or dissect the coronary artery.
                                 

                                Faebinder

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                                  Don't take this the wrong way.... but

                                  at some places, esp those without anesthesia residents, you would rather have the CRNA's doing your case than the gas doc.

                                  as far as solo surgery- its not a big deal for a PA to drop the trocars in solo, or dry up and close. in fact it happens all the time.

                                  Isn't that the american dream? Be in private practice, have a PA closing in 1 room, while another PA is opening in the next? Ideally, with a nurse practitioner taking floor calls and doing the dictations!

                                  You...mmm...I am trying to not call you names. Truly trying. :thumbdown:

                                  I can't wait till PAs get their hands into surgery and then you will start competing with a PA to do an appendectomy and sooner or later hospitals will prefer to hire a PA to do an appendectomy over a surgeon. Great Job :thumbup:
                                   

                                  balaguru

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                                    Probably the biggest hurdle to making this legit is the creation of formal training programs and a certification process. I wonder if this is even possible without the support of the am board of surg. I'm guessing they won't support this. If they ever did set this up the rest would be downhill as medicare would probably be stumbling over themselves to help make it happen.

                                    As to NPs and PAs competing with MDs for residency spots, if DOs are rare birds at allo programs then NPs or PAs should be almost nonexistent. That is unless medicare mandated a quota system which I suppose is a very real possiblity since they are the largest source of funding for GME.
                                     

                                    Emedpa

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                                      Pa's can already do optional postgrad surgical residencies.
                                      these have been in existence for > 20 yrs at places like duke, hopkins, yale, etc
                                      pa residents train alongside md residents and have the same responsibilities as pgy-1 md residents. granted, these residencies train folks to be excellent first assists, not primary surgeons.
                                      see www.appap.org for links to postgrad pa residencies in all specialties.
                                       

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                                        Surgery is the last bastion of medicine that hasnt totally sold out to the midlevels.

                                        I've never heard of a case being run solo by a midlevel the whole way with no attending present. I'm not talking about a PA/NP doing the most critical part of the case with an attending present. I'm talking about 100% solo performance by the midlevel where an attending never even steps into the room.

                                        If you have seen this, I want that scumbag attending's name. I want his home address. I want his phone number.
                                         

                                        Taurus

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                                          Question is how long can surgery hold out the midlevels from doing the surgery while they just supervise? With declining reimbursements, the temptation is there to just supervise a bunch of rooms so that the surgeon can make more money.
                                           

                                          MacGyver

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                                            Question is how long can surgery hold out the midlevels from doing the surgery while they just supervise? With declining reimbursements, the temptation is there to just supervise a bunch of rooms so that the surgeon can make more money.

                                            This is where surgery has done well compared to gas. The gas docs decided long ago that they werent happy with their 250k and wanted to make 350k instead by selling their field out to the CRNAs

                                            So far, surgeons have resisted this temptation, and as a result the average gen surgeon makes quite a bit less than the average anesthesiologist.

                                            Will the surgeons continue to hold the line and take a pay cut to keep their field intact? I'm not optimistic.
                                             

                                            Castro Viejo

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                                              This is where surgery has done well compared to gas. The gas docs decided long ago that they werent happy with their 250k and wanted to make 350k instead by selling their field out to the CRNAs

                                              So far, surgeons have resisted this temptation, and as a result the average gen surgeon makes quite a bit less than the average anesthesiologist.

                                              Will the surgeons continue to hold the line and take a pay cut to keep their field intact? I'm not optimistic.

                                              I look at it from the perspective of liability.

                                              Seeing as how plenty of attending surgeons, at academic and community programs, wouldn't even consider letting a Senior or a Chief Resident perform an operation completely unsupervised (a la "the old days") in the name of "patient safety" or too much liability, I can't see why he would then hand the case over to a PA who, quite frankly, doesn't have the same extensive undergraduate or postgraduate medical training.

                                              Why? Because he will personally train the PA to his liking? Gimme a break. Plenty of attendings already do that year in/year out at the 250+ residency programs in General Surgery, yet I don't see autonomy getting any better for Chiefs at some places.
                                               
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                                              Castro Viejo

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                                                Also, the surgical ego argues against mid-levels ever doing solo cases. Anesthesiologists and Primary Care may be comfortable saying that their "easy" cases are within the realm of nursing practice, but surgery never will. After all, the sugical mantra is that even simple cases can have serious complications, that the surgeon must be ready and able to treat. It would be hard to square this attitude with letting modified-RNs "have at it" in the OR.

                                                Word up.
                                                 

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                                                  I guess what I meant to say is that we all realize that its the older surgeons who sold out the field and when they try to pin the blame on someone else, it ain't washing with me.

                                                  :thumbup:

                                                  This has been one of the things that I've hated most about med school. During MS1 and MS2, we'd get lectures from physicians who would talk about all the problems in medicine - high malpractice premiums, frivolous lawsuits, losing their scope of practice to midlevels, decreasing reimbursements, etc.

                                                  And then, they'd have the gall to wrap up their little depressing speeches with, "Well, it's up to YOU GUYS, as the next generation of doctors, to fix the system!"

                                                  Uh, no. Guess again.

                                                  THEY screwed the system up, by sitting down and shutting up when these problems started looming. And now they're trying to foist the responsibility of finding a solution on US? :thumbdown:

                                                  I'll try to do my part in fixing the system - because I'm worried about my own survival. And because I don't want to pull the same BS with my med students. But I hate being made to feel like I need to clean up someone else's mess.

                                                  As part of my history on patients with hip fractures, I will be asking, "Are you a physician, and if so, have you ever employed an NP or CRNA?" If the answer's yes, you get shortened by 3cm. Welcome to shoe-lift hell, you bastard.

                                                  That's awesome. :laugh:
                                                   

                                                  core0

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                                                    So I was in the OR today talking to the anesthesia resident. She was telling me that she had a patient who came in because of post-LP headache and needed a blood patch. The patient said that a CRNA at an outside hospital in Geauga, OH had done the epidural. On speaking with the CRNA, the resident finds out that midlevels at this hospital are not only during epidurals without any supervision whatsoever but they're also doing some surgeries such as lap appy's without supervision. When did we start allowing midlevels to do surgery solo?
                                                    From Ohio PA statues:
                                                    "(c) No physician assistant shall otherwise perform surgery, act as a surgeon, hold himself or herself out as a surgeon, practice medicine independently, or hold himself or herself out as a physician as defined in Chapter 4731. of the Revised Code. "

                                                    Bottom line, I bet the CRNA was feeding you a line of bull. Ohio has one of the strictest (and worst) PA practice acts in the nation. Given the Ohio medical boards resistance to PA or NP practice, I can pretty much guarantee that it didn't happen.

                                                    It is vaguely possible that someone has interpreted the NP practice act to allow this, but considering that sharp debridement of wounds is essentially prohibited without extensive training, I'm again willing to bet this didn't happen.

                                                    David Carpenter, PA-C
                                                     

                                                    Kubed

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                                                      ...
                                                      Also, the surgical ego argues against mid-levels ever doing solo cases. Anesthesiologists and Primary Care may be comfortable saying that their "easy" cases are within the realm of nursing practice, but surgery never will. After all, the sugical mantra is that even simple cases can have serious complications, that the surgeon must be ready and able to treat. It would be hard to square this attitude with letting modified-RNs "have at it" in the OR.
                                                      :thumbup:
                                                      I wish I had something cleaver to follow up with... but that's just perfect.
                                                       

                                                      Bitsy3221

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                                                        As a former surgical PA and current General Surgery resident, I have done BOTH jobs you are discussing here. From my experiences, I can tell you that those of you who honestly are worried about PAs taking your job should find something more useful to worry about, like a meteor hitting Earth or being attacked by Bigfoot.

                                                        As someone previously mentioned, the overwhelming majority of surgeons (as we have all experienced in countless conferences and interactions) recognize that even the most "minor" operations can have major complications. BY LAW, a PA MUST have a supervising physician in the area they work in--they can not obtain a license or hospital privileges without one. Even those who are employed by hospitals MUST have a supervising physician. This means that any and every PA you have ever seen in the ORs have a SURGEON on their license and hospital credentials. If that PA EVER does anything wrong, that surgeon is liable for any complications. Very, very, very few surgeons (if any) are ever going to put their name or license on the line so much as to allow their PA to operate independently skin-to-skin, even those they have known for years and have trained. These surgeons know that years of "apprenticeship" or even a one year PA surgical residency is no substitute for a medical degree and 5+ years of residency and/or fellowship.

                                                        I was treated well as a PA, and I am treated well as a resident, but I am treated different. My job as a surgical PA was never to train me to become a surgeon, it was to take good, comprehensive care of the surgical patient. Most of that care was outside the OR but some of it was in the OR. So what?? When you get to be a PGY-5, let me know if you really think you needed a few dozen more skin closures to feel competent. And if you WANT to do more vein harvests, then ask the PA to teach you and let you do them when you are on your cardiac rotation. I assure you most of them would be happy to help you. As far as billing, yes, PA's can bill. That is why the attending would sometimes grab me to round with him or her--when short on time we can run through the patients quickly, I can fill out the billing forms as we go and the department makes money. Teaching is imperative for certain, but any department that isn't wise about billing is NOT a place where any of you want to train--trust me.

                                                        The grass is ALWAYS greener on the other side, and as residents I can understand how looking at the midlevels may make you envious, resentful or even worried. But I can assure you as someone who knows many, many, many midlevels and used to BE a surgical PA, they will NEVER take (and by and large don't want) your job as a surgeon. Those few that do will realize that there is a very defined (even if not evident to the residents) ceiling of knowledge, skill and scope as a midlevel and like myself spend a lot of time and money to go back to medical school and do a surgical residency.

                                                        I am not an unintelligent person--there is no way I would have gone through medical school and residency if I could have done what I really wanted to do (be the surgeon) as a PA!
                                                         

                                                        balaguru

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                                                          Thanks for the insight; however, the rules on supervision can always change. In 2001 medicare relaxed supervisory rules for CRNAs by deferring to states and several states took them up on that.

                                                          As a former surgical PA and current General Surgery resident, I have done BOTH jobs you are discussing here. From my experiences, I can tell you that those of you who honestly are worried about PAs taking your job should find something more useful to worry about, like a meteor hitting Earth or being attacked by Bigfoot.

                                                          As someone previously mentioned, the overwhelming majority of surgeons (as we have all experienced in countless conferences and interactions) recognize that even the most "minor" operations can have major complications. BY LAW, a PA MUST have a supervising physician in the area they work in--they can not obtain a license or hospital privileges without one. Even those who are employed by hospitals MUST have a supervising physician. This means that any and every PA you have ever seen in the ORs have a SURGEON on their license and hospital credentials. If that PA EVER does anything wrong, that surgeon is liable for any complications. Very, very, very few surgeons (if any) are ever going to put their name or license on the line so much as to allow their PA to operate independently skin-to-skin, even those they have known for years and have trained. These surgeons know that years of "apprenticeship" or even a one year PA surgical residency is no substitute for a medical degree and 5+ years of residency and/or fellowship.

                                                          I was treated well as a PA, and I am treated well as a resident, but I am treated different. My job as a surgical PA was never to train me to become a surgeon, it was to take good, comprehensive care of the surgical patient. Most of that care was outside the OR but some of it was in the OR. So what?? When you get to be a PGY-5, let me know if you really think you needed a few dozen more skin closures to feel competent. And if you WANT to do more vein harvests, then ask the PA to teach you and let you do them when you are on your cardiac rotation. I assure you most of them would be happy to help you. As far as billing, yes, PA's can bill. That is why the attending would sometimes grab me to round with him or her--when short on time we can run through the patients quickly, I can fill out the billing forms as we go and the department makes money. Teaching is imperative for certain, but any department that isn't wise about billing is NOT a place where any of you want to train--trust me.

                                                          The grass is ALWAYS greener on the other side, and as residents I can understand how looking at the midlevels may make you envious, resentful or even worried. But I can assure you as someone who knows many, many, many midlevels and used to BE a surgical PA, they will NEVER take (and by and large don't want) your job as a surgeon. Those few that do will realize that there is a very defined (even if not evident to the residents) ceiling of knowledge, skill and scope as a midlevel and like myself spend a lot of time and money to go back to medical school and do a surgical residency.

                                                          I am not an unintelligent person--there is no way I would have gone through medical school and residency if I could have done what I really wanted to do (be the surgeon) as a PA!
                                                           

                                                          Bitsy3221

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                                                            Thanks for the insight; however, the rules on supervision can always change. In 2001 medicare relaxed supervisory rules for CRNAs by deferring to states and several states took them up on that.

                                                            Rules will change and "relax" but I can assure you that they will never "relax" to the point that you are concerned about. When I first started years ago I needed supervision to pass NGTs and do ABGs and yes, eventually they "relaxed" the rules enough so I could do them on my own. I hope you don't feel too encroached upon. (I worked many overnight shifts and never once did an intern get angry that I replaced one of the NGT's that mysteriously "fell out" at 2am instead of waking them up to do it.)

                                                            Besides whatever the states may legislate, the individual hospitals often have separate and often more strict rules governing midlevels. While they want to make money, they often are not the ones employing the PAs and do not want to put themselves in the firing line of a big med mal suit. As we have ALL seen here, suits where midlevels made a mistake are often big news and big money.

                                                            My point is, there is so much more we need to worry about as young surgeons than if the midlevels are going to take our jobs away from us.
                                                             

                                                            Taurus

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                                                              I wouldn't make assumptions about the future. 10 years ago, who would have imagined CRNA's being able to deliver gas unsupervised? Who would have imagined the "Doctor nurse" degree? Who would have imagined that the NBME would create an exam for these DNP's?

                                                              Declining reimbursements are putting a heavy pressure on surgeon salaries. I wouldn't be surprised to hear one day about surgeons supervising multiple rooms while midlevels do simple cases.
                                                               

                                                              Bitsy3221

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                                                                I wouldn't make assumptions about the future. 10 years ago, who would have imagined CRNA's being able to deliver gas unsupervised? Who would have imagined the "Doctor nurse" degree? Who would have imagined that the NBME would create an exam for these DNP's?

                                                                Declining reimbursements are putting a heavy pressure on surgeon salaries. I wouldn't be surprised to hear one day about surgeons supervising multiple rooms while midlevels do simple cases.

                                                                If that scenerio ever happens, it is going to be US (medical students and residents currently in training) that allows this and supervises them. Even if you put aside the fact that most midlevels have no desire to do complete surgeries independently, if PAs were ever to be doing "simple cases" on their own in separate rooms, they are going to have to have surgeons who agreed to train and subsequently supervise them. Judging from the attitudes of those in this forum and out there, we--the next generation of surgeons--would never allow that. I know I wouldn't.

                                                                Last I checked, anesthesiologists and surgeons have very, very different jobs (and having done an anesthesia rotation this year I can attest to this), so I don't think citing the intermittant popularity of CRNAs as a sign of things to come is at all valid. And whether you choose to accept it or not, CRNAs are not "unsupervised"--every case I have done with them in multiple hospitals in multiple states has the attending anesthesiologist present during induction and present during extubation if there is any inkling there may be difficulty. They always page the attending to let them know they are getting ready to extubate. If an unexpected problem arises, they call the attending and he/she is there quickly. Those cases are quite frankly no different than the cases we do with junior anesthesia residents. If you have a different experience, you should direct your outrage toward the anesthesiologists who are allowing this, not the CRNAs.
                                                                 

                                                                Taurus

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                                                                  And whether you choose to accept it or not, CRNAs are not "unsupervised"--every case I have done with them in multiple hospitals in multiple states has the attending anesthesiologist present during induction and present during extubation if there is any inkling there may be difficulty. They always page the attending to let them know they are getting ready to extubate. If an unexpected problem arises, they call the attending and he/she is there quickly. Those cases are quite frankly no different than the cases we do with junior anesthesia residents. If you have a different experience, you should direct your outrage toward the anesthesiologists who are allowing this, not the CRNAs.

                                                                  You should post that statement in the anesthesiology forum. They would have a good laugh. Everyone wishes what you said is true. 14 states have opted out of anesthesiology supervision.

                                                                  * Iowa (December 2001)
                                                                  * Nebraska (February 2002)
                                                                  * Idaho (March 2002)
                                                                  * Minnesota (April 2002)
                                                                  * New Hampshire (June 2002)
                                                                  * New Mexico (November 2002)
                                                                  * Kansas (March 2003)
                                                                  * North Dakota (October 2003)
                                                                  * Washington (October 2003)
                                                                  * Alaska (October 2003)
                                                                  * Oregon (December 2003)
                                                                  * Montana (January 2004)
                                                                  * South Dakota (March 2005)
                                                                  * Wisconsin (June 2005)


                                                                  In these states, there are even CRNA only groups that compete with anesthesiology groups for contracts.

                                                                  Both anesthesiology and surgery can be very technical. You can train a monkey to do the technical stuff like lap appy's and chole's.
                                                                   
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                                                                  Taurus

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                                                                    in theory aren't crna's in those 14 states still supervised by the attending surgeon?

                                                                    Bingo. If the CRNA screws up, guess who's getting named on the lawsuit? The supervising physician or surgeon. In court, the CRNA will simply say that they're taking orders and shouldn't be held liable. They will put all the liability on the surgeon's shoulders.

                                                                    It's a pretty sweet gig to be a CRNA in my opinion.
                                                                     

                                                                    Bitsy3221

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                                                                      Bingo. If the CRNA screws up, guess who's getting named on the lawsuit? The supervising physician or surgeon. In court, the CRNA will simply say that they're taking orders and shouldn't be held liable. They will put all the liability on the surgeon's shoulders.

                                                                      It's a pretty sweet gig to be a CRNA in my opinion.

                                                                      What?? Since when do surgeons supervise CRNAs? While it is true that on lawsuits, they will often name EVERYONE ever involved on the case, most of those names get plucked off as the case evolves and it becomes clear that it is not finincially viable to go after the surgeon if it is an anesthesia error and vice versa.

                                                                      Seriously, where do you get your information?? I genuinely don't want this to come across as a personal attack, but so much of this midlevel-fearing stuff you spew is really off base. While there is ALWAYS anecdotal info to support any scenerio and any situation and everyone "knew this one guy...", these pictures you paint of incompetent midlevels running willy-nilly with no supervision in sight actively killing patients left and right is hardly based in reality. Why do you have so much all-out hatred for all non-physicians?
                                                                       

                                                                      Taurus

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                                                                        What?? Since when do surgeons supervise CRNAs? While it is true that on lawsuits, they will often name EVERYONE ever involved on the case, most of those names get plucked off as the case evolves and it becomes clear that it is not finincially viable to go after the surgeon if it is an anesthesia error and vice versa.

                                                                        Seriously, where do you get your information?? I genuinely don't want this to come across as a personal attack, but so much of this midlevel-fearing stuff you spew is really off base. While there is ALWAYS anecdotal info to support any scenerio and any situation and everyone "knew this one guy...", these pictures you paint of incompetent midlevels running willy-nilly with no supervision in sight actively killing patients left and right is hardly based in reality. Why do you have so much all-out hatred for all non-physicians?

                                                                        We've discussed this ad nauseam in anesthesiology forum. A number of members personally know of cases where the surgeon uses the service of the CRNA and something goes wrong. In court, the CRNA claims to be just working under supervision of the surgeon, even though it's arguable that it was anesthesia-related. In the end, both surgeon and CRNA get sued and lose. The surgeon gets the much higher bill. Why? Because CRNA's portray themselves as nurses. The public and lawyers still think that the physicians and surgeons have the deep pockets and that's why they target you.

                                                                        Read the practice acts of CRNA's. By law, CRNA's can only deliver anesthesia if ordered by physician, surgeon, or dentist. Therefore, the surgeon who works with an independent CRNA becomes their supervising doctor and therefore assumes liability. The ASA put out a statement to this effect. If I find it, I'll post the link.

                                                                        What's that saying? "If you don't learn from history..."
                                                                         

                                                                        Bitsy3221

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                                                                          I took your advice and read a bit about the practice acts regarding CRNAs. Since I deal in facts and not anecdotes, I thought you may find this legal brief interesting:

                                                                          "Because the majority of anesthesia accidents arise from a lack of vigilance, it seems fairly elementary that a surgeon looking for an anesthesia provider should look for someone vigilant, well-organized, and someone with whom the surgeon can work easily. The type of license the anesthetist holds, whether MD or CRNA, is irrelevant to the quality of care they render. Yet many surgeons have been told, and a surprising number actually believe, that whether the provider is a nurse anesthetist or an anesthesiologist affects the surgeon's liability. Some surgeons have been told that they are liable for the negligence of nurse anesthetists but do not need to worry about "what goes on at the head of the table" when they work with anesthesiologists.

                                                                          This column has pointed out that the principles governing the liability of a surgeon for anesthesia are the same whether the surgeon works with a nurse anesthetist or an anesthesiologist. The liability of a surgeon for anesthesia is most often based on whether the surgeon controls the anesthesia provider which depends on the facts of the case not on the status of the anesthesia provider. In the past, we have highlighted cases which either clarify these principles or typify cases in which surgeons have not been held liable for the negligence of a nurse anesthetist..."

                                                                          Full brief here if interested:
                                                                          http://www.aana.com/resources.aspx?...MenuTargetType=4&ucNavMenu_TSMenuID=6&id=2362
                                                                           

                                                                          Taurus

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                                                                            I took your advice and read a bit about the practice acts regarding CRNAs. Since I deal in facts and not anecdotes, I thought you may find this legal brief interesting:

                                                                            "Because the majority of anesthesia accidents arise from a lack of vigilance, it seems fairly elementary that a surgeon looking for an anesthesia provider should look for someone vigilant, well-organized, and someone with whom the surgeon can work easily. The type of license the anesthetist holds, whether MD or CRNA, is irrelevant to the quality of care they render. Yet many surgeons have been told, and a surprising number actually believe, that whether the provider is a nurse anesthetist or an anesthesiologist affects the surgeon's liability. Some surgeons have been told that they are liable for the negligence of nurse anesthetists but do not need to worry about "what goes on at the head of the table" when they work with anesthesiologists.

                                                                            This column has pointed out that the principles governing the liability of a surgeon for anesthesia are the same whether the surgeon works with a nurse anesthetist or an anesthesiologist. The liability of a surgeon for anesthesia is most often based on whether the surgeon controls the anesthesia provider which depends on the facts of the case not on the status of the anesthesia provider. In the past, we have highlighted cases which either clarify these principles or typify cases in which surgeons have not been held liable for the negligence of a nurse anesthetist..."

                                                                            Full brief here if interested:
                                                                            http://www.aana.com/resources.aspx?...MenuTargetType=4&ucNavMenu_TSMenuID=6&id=2362

                                                                            If you're so into research, consider your source. The AANA is the body that represents CRNA's. The ASA has a different view. The proof is in the pudding - real life cases. When a patient dies on the table, it's not always so easy to tell whose at fault. Therefore, you'll both be dragged into court and you'll be stuck with a higher legal bill because the jury will assume you're the rich doctor and the CRNA as the hard-working, barely scraping-by nurse (even though they average $150k now).

                                                                            Think for a second. Why do obstreticians have such high malpractice premiums? Are they always responsible for the developmental defects? No. It's because the jury will see that poor CP baby who can barely move and they will think that you being the rich doctor can help defray the cost of raising the kid.

                                                                            Why do you think that anesthesiologists like to joke that CRNA's have their cake and eat it too? They make a ton of money for their measly education and yet enjoy little liability exposure because they're either hiding behind the anesthesiologist or the surgeon. It's a sweet gig.

                                                                            Btw, what you posted is not the CRNA practice act for a state. It's propaganda from the CRNA's which they are very good at. They are so powerful now that they are the 10th largest health-related PAC in Washington, DC.
                                                                             

                                                                            core0

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                                                                              You should post that statement in the anesthesiology forum. They would have a good laugh. Everyone wishes what you said is true. 14 states have opted out of anesthesiology supervision.

                                                                              * Iowa (December 2001)
                                                                              * Nebraska (February 2002)
                                                                              * Idaho (March 2002)
                                                                              * Minnesota (April 2002)
                                                                              * New Hampshire (June 2002)
                                                                              * New Mexico (November 2002)
                                                                              * Kansas (March 2003)
                                                                              * North Dakota (October 2003)
                                                                              * Washington (October 2003)
                                                                              * Alaska (October 2003)
                                                                              * Oregon (December 2003)
                                                                              * Montana (January 2004)
                                                                              * South Dakota (March 2005)
                                                                              * Wisconsin (June 2005)


                                                                              In these states, there are even CRNA only groups that compete with anesthesiology groups for contracts.

                                                                              Both anesthesiology and surgery can be very technical. You can train a monkey to do the technical stuff like lap appy's and chole's.
                                                                              This is incorrect. CRNAs compete for anesthesia contracts in every state. The opt out allows the states to opt out of Medicare rules regarding supervision by physicians. From farther on down the same paper you quoted from:
                                                                              " *
                                                                              The federal requirement has been that CRNAs must be supervised by a physician. The November 13, 2001 rule allows states to "opt-out" or be "exempted" (the terms are used synonymously in the November 13 rule) from the federal supervision requirement."

                                                                              Prior to this the assumption was that the CRNA was supervised by the surgeon in the absence of an ACT practice. This removed that requirement. I am not aware of any rule anywhere that mandates anesthesiologist supervision whether its state regulation or federal payment rules. The CRNAs got a sweet deal when they managed to become the only NPP who get 100% reimbursement without working in a collaborative relationship with a physician.

                                                                              Both anesthesiology and surgery can be very technical. You can train a monkey to do the technical stuff like lap appy's and chole's.
                                                                              Given the number of biliary injuries we see here, apparently its a little harder than that. I will let the real surgeons comment on the number of "ordinary" appy's that weren't. There is a reason that surgical residencies are five years long.

                                                                              David Carpenter, PA-C
                                                                               

                                                                              Bitsy3221

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                                                                                The ASA has a different view. The proof is in the pudding - real life cases. When a patient dies on the table, it's not always so easy to tell whose at fault. Therefore, you'll both be dragged into court and you'll be stuck with a higher legal bill because the jury will assume you're the rich doctor and the CRNA as the hard-working, barely scraping-by nurse (even though they average $150k now).

                                                                                Yes, I am into research. SHOW ME the cases you are talking about. SHOW ME the ASA viewpoint. I am well aware of who the AANA is and who they represent. I am also well aware that there is a difference in a legal brief and a practice act. But if we are discussing legal liability here, I think written briefs from med mal lawyers is more useful that a vague, unnamed reference to an anonymous "I once saw this one case..." followed by "yeah me too..." posting on the SDN Anesthesia board is a bit more useful.

                                                                                You spewing off all this nebulous "CRNA's suck" and "PAs suck" and "NPs suck" is of no utility and has no more basis than these patients we have all encountered who hate ALL doctors and think ALL doctors are greedy, incompetent, uncaring and rich a-holes who are only out to make their next buck. I'm sure you don't like being held accountable for every physician in every specialty's previous errors and misdeeds, so why do you do the same to midlevels?
                                                                                 

                                                                                Dr.Millisevert

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                                                                                  I took your advice and read a bit about the practice acts regarding CRNAs. Since I deal in facts and not anecdotes, I thought you may find this legal brief interesting:

                                                                                  "Because the majority of anesthesia accidents arise from a lack of vigilance, it seems fairly elementary that a surgeon looking for an anesthesia provider should look for someone vigilant, well-organized, and someone with whom the surgeon can work easily. The type of license the anesthetist holds, whether MD or CRNA, is irrelevant to the quality of care they render. Yet many surgeons have been told, and a surprising number actually believe, that whether the provider is a nurse anesthetist or an anesthesiologist affects the surgeon's liability. Some surgeons have been told that they are liable for the negligence of nurse anesthetists but do not need to worry about "what goes on at the head of the table" when they work with anesthesiologists.

                                                                                  This column has pointed out that the principles governing the liability of a surgeon for anesthesia are the same whether the surgeon works with a nurse anesthetist or an anesthesiologist. The liability of a surgeon for anesthesia is most often based on whether the surgeon controls the anesthesia provider which depends on the facts of the case not on the status of the anesthesia provider. In the past, we have highlighted cases which either clarify these principles or typify cases in which surgeons have not been held liable for the negligence of a nurse anesthetist..."

                                                                                  Full brief here if interested:
                                                                                  http://www.aana.com/resources.aspx?...MenuTargetType=4&ucNavMenu_TSMenuID=6&id=2362

                                                                                  I do agree that you cannot use the AANP "views" as a valid source of what your actually liability would be. (you wouldn't be able to find a more biased source than their website)

                                                                                  I also agree that we would like some hard facts regarding this issue. The main thing would be to find out if there were any precedents set in any US states where a surgeon was held responsible for supervising a CRNA and then held liable.

                                                                                  Hopefully we can get to the bottom of this issue.

                                                                                  One thing that I do find odd though... is why CRNAs who are allowed to practice "unsupervised" are not required to pay more malpractice insurance than board certified anesthesiologists who do the same job. If I'm a 35 year old male who has more experience and education and has not had any accidents.. my auto insurance will be a lot cheaper than a 16 year old who has less experience and who may not be as safe a driver.

                                                                                  Its only logical that more education and more experience = safer/better medical care (if you disagree with this.. then I don't know what else to say) :)

                                                                                  Why then would any CRNA be able to pay equal to or less than any BC Anesthesiologist in annual malpractice??
                                                                                   

                                                                                  Taurus

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                                                                                    Found this in the ASA's website from 2000. I'm sure there's something more recent, but nothing else popped up in my 30 search between qBank tests.

                                                                                    "Surgeon Liability for Nurse Anesthetists: Fact or Fiction?"

                                                                                    http://www.asahq.org/Newsletters/2000/12_00/semo.htm

                                                                                    The controlling factor in determining whether a surgeon is to be held accountable for a nurse anesthetist's actions is whether, based on the facts of the case, the surgeon actually exercised control or had the right to exercise control over the nurse anesthetist during the surgical procedure. If not, the surgeon is likely not to be held accountable for the actions of the nurse anesthetist or adverse patient outcomes resulting from the administration of anesthesia. Under this control or right to control test, the scope of practice of the nurse anesthetist under state law is less important. Whatever state law provides, if a hospital requires some level of physician oversight of anesthesia services, or if the surgeon intervenes in the administration of anesthesia, the surgeon may be found liable for a nurse anesthetist's actions.​

                                                                                    Thanks for posting the link.

                                                                                    The members of the anesthesiology forum essentially concluded this. When working with an independent CRNA and the patient develops problems, the surgeon can avoid being dragged into court with the CRNA only if they put their hands up and walk away from the table and lets the CRNA handle the emergency. If the surgeon starts to instruct the CRNA to give pressors, muscle relaxants, etc then the surgeon becomes the overseer of the CRNA and therefore can be and have been found liable. What surgeon will walk away from the table during an emergency during surgery? In court, the CRNA will claim that they're just a nurse and taking orders from the surgeon.
                                                                                     

                                                                                    Taurus

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                                                                                      One thing that I do find odd though... is why CRNAs who are allowed to practice "unsupervised" are not required to pay more malpractice insurance than board certified anesthesiologists who do the same job. If I'm a 35 year old male who has more experience and education and has not had any accidents.. my auto insurance will be a lot cheaper than a 16 year old who has less experience and who may not be as safe a driver.

                                                                                      That's a good question that I have raised again and again.

                                                                                      An independent CRNA's malpractice is only 1/10 of an anesthesiologist. Somehow, the insurance companies think that a CRNA has less liability exposure. The only thing I could conclude is that a CRNA can reduce his liability by hiding behind an anesthesiologist or surgeon.
                                                                                       

                                                                                      SLUser11

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                                                                                        here is another Q
                                                                                        at your program who does ICP bolts?
                                                                                        NS resident, NS attending, Trauma resident, Trauma attending?
                                                                                        Are residents allowed to do them without supervision?

                                                                                        i ask b/c at our program the NS attending sdont want to do them
                                                                                        and we dont have NS residents
                                                                                        so the trauma residents put them in
                                                                                        but if thats the case
                                                                                        do you need supervision for that procedure??

                                                                                        I do bolts frequently, and almost always unsupervised. I also have absolutely no aspirations to do them when I'm in practice. Like someone else said, you could hypothetically hit the saggital sinus and kill the patient in a few minutes. Of course, as far as dealing with your own complications, if you cause an intracranial bleed putting it in, you DO have the hand drill out already....

                                                                                        The reason we do them is that there are no neurosurgery residents, and we run the Trauma ICU.
                                                                                         

                                                                                        core0

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                                                                                          That's a good question that I have raised again and again.

                                                                                          An independent CRNA's malpractice is only 1/10 of an anesthesiologist. Somehow, the insurance companies think that a CRNA has less liability exposure. The only thing I could conclude is that a CRNA can reduce his liability by hiding behind an anesthesiologist or surgeon.
                                                                                          I can't find exact numbers for CRNA malpractice, but from what I hear this seems accurate. You have to remember that there are a variety of factors that make up malpractice insurance. On the liability side there is perceived and actual risk based on the track record for providing insurance and where the company thinks the market is going. On the other side is the amount of providers the cost is spread over and the quality (from a risk standpoint) of the providers.

                                                                                          For the CRNA market, risk remains relatively low as it does for all anesthesia providers. That being said there are companies that stratify based on solo CRNA practice, group CRNA practice, MD and CRNA practice and Locums Tenums work. Interestingly Locums in these groups has the highest premium. In the case of CRNAs, there is also a matter of subsidy. Most CRNAs (from what I understand) get their insurance through AANA as a member benefit. This same group also provides insurance to the students. In this case given the low claims rates this effectively subsidizes working CRNAs.

                                                                                          Also consider that physicians are exposed to areas that CRNAs (traditionally) are not. For example critical care carries more liability exposure than anesthesia. I am guessing that pain also carries more liability exposure than anesthesia (CRNAs practicing pain are probably largely under the radar here).

                                                                                          Finally there is at least one state that considered non-act CRNAs having a higher liability than CRNAs in ACT practice:
                                                                                          http://www.nmana.org/NMmalprac-ins2.htm

                                                                                          Overall, its probably a combination of subsidy, low claims rates and a broad population with competition from the market. If the claims rates rise (which they have been for all NPPs) then the rates will also rise. From a PA perspective, PAs doing anesthesia are put in the middle risk category (less than CVS or OB more than general medicine.

                                                                                          David Carpenter, PA-C
                                                                                           

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                                                                                            Found this in the ASA's website from 2000. I'm sure there's something more recent, but nothing else popped up in my 30 search between qBank tests.

                                                                                            "Surgeon Liability for Nurse Anesthetists: Fact or Fiction?"

                                                                                            http://www.asahq.org/Newsletters/2000/12_00/semo.htm

                                                                                            Thanks for the link. My take home message from this is that most of the time, the surgeon is not liable for the CRNA but surgeons can and will be sued for bad CRNA practice.

                                                                                            The way the law works for this particular area is ridiculous. One of the case reports in that link said that the surgeon was held liable SOLELY BECAUSE THE STATE NURSING PRACTICE ACT DECLARED THAT CRNAS ARE PART OF THE HEALTHCARE TEAM (as opposed to being true independents). The court used that statement to conclude that the surgeon was automatically liable for the CRNA's actions (as there was no anesthesiologist for that case), REGARDLESS of what actually happened in the OR. Absolutely ****ing outrageous.

                                                                                            Another part of that link that pisses me off is the insinuation that any instruction to the CRNA, no matter how trivial, results in automatic assumption of supervisory capacity and liability. That means if I tell the CRNA to put the patient in reverse-T that I'm on the hook for some anesthesia botch job by the CRNA at the end of the case, because I started "supervising" the CRNA the moment I gave that "order."

                                                                                            The bottom line is this: surgeons should choose a state to practice in which the state regulations are clear and unequivocal that CRNAs are 100% independent providers. Any state practice act which states that CRNAs are "part" of the healthcare team means that the surgeon is liable for their incompetence.
                                                                                             

                                                                                            Taurus

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                                                                                              Given the number of biliary injuries we see here, apparently its a little harder than that. I will let the real surgeons comment on the number of "ordinary" appy's that weren't. There is a reason that surgical residencies are five years long.

                                                                                              When midlevels were first given script privileges, doctors cried out that they would kill patients. Didn't happen. When NP's were given autonomy mostly in outpatient settings, doctors cried out that they would kill patients. Didn't happen. When CRNA's were allowed autonomy, you don't see an increase in deaths.

                                                                                              While I appreciate that crises can erupt at any moment in surgery because of a nicked vessel or whatnot, the question is does it really require 4 years of medical school and 5 years of residency to do simple surgeries such as lap appy's or chole's or reducing fractures? If someone does a procedure often enough, that person can get pretty skilled doing it, even if they are a midlevel. Technical skill is learned through repetition.

                                                                                              I personally would never want a midlevel to do my surgery, but as reimbursements decrease I wonder if some pioneering surgeon will decide to go from doing the surgeries himself to just supervising a bunch of rooms. After all, he would be available if trouble happens. Once that happens, it's just a skip and a throw before they next ask for autonomy in surgery.
                                                                                               
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