New CV Surgeon wants his own strike team

[siednarb]

New CV Surgeon joined hospital I work at - claims he has watched Shuttle launches and says it's a choreographed dance and he wants that in his heart room where everyone knows his moves.

Our group has 8 CV physicians and 24 CRNAs who are competent to be in the heart room.

He is asking for no more than 3 of our CV physicians and only 5 CRNAs that are allowed in his rooms. He doesn't have an issue with anyone in particular - he just wants a small group that only works with him.

This is a bit complicated from a scheduling standpoint for both physicians and CRNAs in our group (post-call, vacation, etc...)

We proposed keeping our 8 physicians that work the heart rooms and reduced CRNAs from 24 to 13 - but still not happy and he has the hear of cardiology getting involved in this fight.

Just wondering if other hospitals out there have such a set up with only a limited number of anesthesia physicians and CRNAs dedicated to following one heart surgeon and if so how do you make that work from a scheduling standpoint. Or is this CV surgeon's demand just far fetched.

We probably do about 250 open heart cases a year and he is not the only CV surgeon - just the new one.

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[GassYous]

What the ****...

 

[DrOwnage]

So glad I didn't do a cardiac fellowship...

 

[anbuitachi]

give him the schedule of 3 attendings and 5 crnas and tell him if he wants to work with them, only book cases when they are available

 

[FiO2@21]

And this is how I found out we let CRNAs in the heart room...

 

[2Fast2Des]

give him the schedule of 3 attendings and 5 crnas and tell him if he wants to work with them, only book cases when they are available

Exactly... First of all WTF.... 2nd, I really hope you guys have some balls and tell the new guy to sit back and stfu, you're not some circulator or scrub tech that they can choose. 3rd don't need a CV fellowship when CRNAs are demanded to be on the short list. 4th, WTF??

 

[IlDestriero]

If wishes were horses, poor men would ride.

 

[GassYous]

Tell that douchebag that you request only the other surgeons

 

[nimbus]

I think that surgeon has a point. These smaller close knit groups that work together all the time generally perform better than larger groups that work with each other only occasionally. If smooth seamless performance is the top priority, that is the best way to achieve it in my opinion. I think we’ve all seen it. Of course, there are other priorities and considerations in the OR. If I were having heart surgery, I would want a team that worked together all day every day for over a decade.

 

[JiPo]

And this is how I found out we let CRNAs in the heart room...

I don’t think having crnas in heart room is a problem as long as it is 1:1 coversge and the anesthesiologist does not let them do lines or touch TEE probe. I mean, does the attending really have to be in the room during bypass?

i hope that is the set up at OP’s shop.

 

[dchz]

We probably do about 250 open heart cases a year and he is not the only CV surgeon - just the new one.

There is a simpler solution here. That's less than 120 cases per year assuming 2 surgeons why do you even need 8 physicians to cover 250 cases? Just have the physician solo them. Which would actually make your group money, "cardiac" CRNAs aren't cheap.

And this is how I found out we let CRNAs in the heart room...

You realize there are placed where the CRNA pretty much does the whole case and the physician is there as a fire fighter. right? The CRNAs are even "proficient" in TEE.

I don’t think having crnas in heart room is a problem as long as it is 1:1 coversge and the anesthesiologist does not let them do lines or touch TEE probe. I mean, does the attending really have to be in the room during bypass?

i hope that is the set up at OP’s shop.

LOL this is where I point out you've only been in the ivory towers of the NE. in the swamps of the SE the type of practice you just described is a money loser. Why not just pay the physician both salaries (give physician the CRNA salary) and have him be solo?

give him the schedule of 3 attendings and 5 crnas and tell him if he wants to work with them, only book cases when they are available

Why even give him CRNAs? just have the physicians solo the case....???

I think that surgeon has a point. These smaller close knit groups that work together all the time generally perform better than larger groups that work with each other only occasionally. If smooth seamless performance is the top priority, that is the best way to achieve it in my opinion. I think we’ve all seen it. Of course, there are other priorities and considerations in the OR. If I were having heart surgery, I would want a team that worked together all day every day for over a decade.

This 100%. The top surgeons here only have the most experienced rockstars in their room (physician only group). As the new guy, I don't even expect to be in their room for years. I don't have enough of an ego to think this is a problem. If I was the patient, I'd want it that way too. Even though there are 25+ CT guys in my group, I see a pattern in how there is usually always the same pairing. I don't think anesthesiologists have problems with this either.... if it wasn't for the billing and the ACT model demanding you need to supervise more rooms or you don't make money.



As with posts like this, it's helpful to present both perspectives.

Surgeon: I'm new here, having a smaller team helps my transition and allows me to be more comfortable in a very complex situation that is CPB and heart surgery. Which, ultimately leads to better outcomes to patients.

Anes team: we've established a certain practice model and standard of living, we have fixed costs in CRNA salary and Physician expected salary. Restricting the # of people in his room would make our current practice model much harder.

The resolution of this will ultimately be determined by the leverage the CT surgeon has on the hospital and the leverage anesthesiologists have. Which is hard to determine in OP's case, but what i've seen the CT surgeons usually have more leverage.

They simplest solution I see is just have 3 Physicians solo his cases, which would mean ~40 cases per year each. Then hire another generalist to supervise your other rooms. Math on this would actually make more money for the group.

Also i can already foresee this being a private forum topic if we are going to discuss further.

 

[nimbus]

I don’t think having crnas in heart room is a problem as long as it is 1:1 coversge

Seriously that is one too many warm bodies.

 

[deleted126335]

New CV Surgeon joined hospital I work at - claims he has watched Shuttle launches and says it's a choreographed dance and he wants that in his heart room where everyone knows his moves.

Our group has 8 CV physicians and 24 CRNAs who are competent to be in the heart room.

He is asking for no more than 3 of our CV physicians and only 5 CRNAs that are allowed in his rooms. He doesn't have an issue with anyone in particular - he just wants a small group that only works with him.

This is a bit complicated from a scheduling standpoint for both physicians and CRNAs in our group (post-call, vacation, etc...)

We proposed keeping our 8 physicians that work the heart rooms and reduced CRNAs from 24 to 13 - but still not happy and he has the hear of cardiology getting involved in this fight.

Just wondering if other hospitals out there have such a set up with only a limited number of anesthesia physicians and CRNAs dedicated to following one heart surgeon and if so how do you make that work from a scheduling standpoint. Or is this CV surgeon's demand just far fetched.

We probably do about 250 open heart cases a year and he is not the only CV surgeon - just the new one.

Pick his team from the "problem children/difficult to work with" Anesthesiologists and CRNAs.

 

[ryanjmy]

Surgeon is right. You’re CRNA’s are only getting 10 cv cases a year. Anesthesiologists are only getting 30 cases a year. You‘d get improved quality by having a more dedicated heart team. Figure out what it would cost (call stipend) to go down to 6 CRNAs and 3 MDs. Present it to administration and see what they say.

 

[chocomorsel]

Surgeon is right. You’re CRNA’s are only getting 10 cv cases a year. Anesthesiologists are only getting 30 cases a year. You‘d get improved quality by having a more dedicated heart team. Figure out what it would cost (call stipend) to go down to 6 CRNAs and 3 MDs. Present it to administration and see what they say.

Again. Why even include the CRNAs?

 

[abolt18]

Again. Why even include the CRNAs?

Probably to set up the room

 

[ryanjmy]

Again. Why even include the CRNAs?

I’ve done it both ways. From a pure economic standpoint you are right. But if the hospital is willing to pay for it who cares? If a pt is truly crashing it helps to have an extra set of hands. Been there done that.

Administration will spend money in the name of improved quality especially to keep a heart surgeon happy. If not op has a scape goat.

 

[Southpaw]

They simplest solution I see is just have 3 Physicians solo his cases, which would mean ~40 cases per year each. Then hire another generalist to supervise your other rooms. Math on this would actually make more money for the group.

Also i can already foresee this being a private forum topic if we are going to discuss further.

Let's assume the group is fairly astute with what cases produce a profit and what cases do not. How would having 1 physician do solo anesthesia in a low volume cardiac room, presumably all Medicare cases, and then hiring another anesthesiologist to supervise the general rooms that the cardiac anesthesiologist would have been supervising, be profitable?

Also, while I don't think it's a bad idea to suggest the physician do the cardiac case MD only, in the large majority of places where the physician has been primarily, or completely, supervising if you were to walk in and suggest they now do their cases solo, especially cardiac, they will look at you as if you have totally, and completely, lost your mind. Notice, I'm not saying it's a bad idea, but I am saying that on this board when we have historically suggested a change in the model, my guess is that suggestion has been implemented absolutely, and totally, 0% of the time. And that it'll be that way going forward. The group already has a bunch of anesthesiologists and CRNAs. Changing their model simply won't happen unless forced upon them by some hospital/AMC overlords. Although, like you, I wish it would.

Also, lastly, and I know I don't have to tell you because it's what you picked, but you are working in a very good group with a very solid model.

 

[dchz]

How would having 1 physician do solo anesthesia in a low volume cardiac room, presumably all Medicare cases, and then hiring another anesthesiologist to supervise the general rooms that the cardiac anesthesiologist would have been supervising, be profitable?

Cost for 5 cases:

Current model: 4 CRNAs + 1 "cardiac" CRNA (this person usually is more senior and commands more pay) + 1.5 physician pay (assuming 2:1 hearts supervision)

Model i suggested. 4CRNAs + 2 physician pay.

My model is profitable from a pure number point of view if the "cardiac" CRNA's pay is more than half of the physician's pay. I realize this is purely theoretically and the cost of changing culture is way more pricy as you suggested.

 

[Southpaw]

Cost for 5 cases:

Current model: 4 CRNAs + 1 "cardiac" CRNA (this person usually is more senior and commands more pay) + 1.5 physician pay (assuming 2:1 hearts supervision)

Model i suggested. 4CRNAs + 2 physician pay.

My model is profitable from a pure number point of view if the "cardiac" CRNA's pay is more than half of the physician's pay. I realize this is purely theoretically and the cost of changing culture is way more pricy as you suggested.

One can assume the OPs group isn't paying more for cardiac CRNAs because they have so many in the pool for low volume cardiac. Either way they don't need that many CRNAs or physicians in the cardiac pool for that volume. But there's no real reason for a cardiac CRNA to command more pay than other CRNAs. If that's the case, and I were a CRNA, then you can certainly put me in the cardiac room. FWIW, paying more for a 'cardiac' CRNA must be regional bc I've never heard of it.

Also, in your model you have 1 physician doing their own low volume room all day every day. And the other physician supervising 4:1 all day every day. Can you guess which of those roles is profitable for the group? Would that lead to discord? Certainly the person working 4:1 is working much harder all day everyday than the person doing their own case. Also, the physician doing their own case now takes cardiac call, and perhaps falls out of the general call group. No more getting woken up for epidurals, appys, food boluses, and whatever else shows up at 2am. In your model, I find discord and disruption, but if not, then sign me up for the cardiac room. Do I get more pay also for bringing less money to the group?

Anyway, to the OPs situation, the surgeon is going to have admin's ear most likely based on what's been said. My guess is at minimum you'll have to bend some to accommodate. You certainly already have too many people in a lowish volume pool, but my guess is that it's worked out for your group because of how your setup is.

 

[sevoflurane]

Unless there is a skillset or personality conflict, this NEW CT surgeon can go F himself. He has ZERO business trying to tell your group how to staff it. What happens at 1am when a type A comes in? You going to ask the non-call ct anes guy on his special list to come in? So arrogant. Tell your chief of CT to grow some balls. If he is new, he likely has a lot to learn still.

 

[sevoflurane]

BTW 8 md’s and 24 crna’s is ludicrous for 250 cases. I probably misses something in the thread. Nobody is going to maintain a good skillset w/that many people.

 

[sevoflurane]

You realize there are placed where the CRNA pretty much does the whole case and the physician is there as a fire fighter. right? The CRNAs are even "proficient" in TEE.

Pretty much does the whole case? W in the actual F. Weak departments like these make me sick and are largely the reason we are where we are.

 

[IMGASMD]

BTW 8 md’s and 24 crna’s is ludicrous for 250 cases. I probably misses something in the thread. Nobody is going to maintain a good skillset w/that many people.

That makes me think there must be an incentive somewhere to be on the cardiac team. Someone doesn’t want to give up that perk.
That’s 30 cases a year for physicians and 10 case per crna.
Good for those who feel “comfortable” doing hearts 2 times a months. I personally wouldn’t.

My bet is there is money somewhere, someone is holding onto for very little work. We just don’t know.

Or they staff another hospital, CTICU. But a lot of speculation.

250 cases for 8 physicians and 24 crnas just don’t make any sense.

 

[IMGASMD]

Pretty much does the whole case? W in the actual F. Weak departments like these make me sick and are largely the reason we are where we are.

I’ve heard physicians do lines, crna intubate and stay at the head. Possible a-lines. TEE done by physician; however, there are people who are okay letting crna “try”. Just like for neuroaxial and blocks, “depends on practitioner comfort”.
Hogwash, I know.
But I asked the other day, if asa-pac and ppp can’t/won’t do anything about it..... what can “I” do? I am serious!

 

[Man o War]

My group would not honor this request. We can’t scheduling wise. However, we already have a smaller group of docs only doing hearts so everyone stays very proficient. Your group has too many heart guys/gals for your volume IMO.
This may come down to a needed infrastructure change in your group depending on how insistent this guy is going to be.

 

[circleK]

We have this model for the whole heart program, but have had it since we started doing hearts here 14 years ago, so didn’t have to really transition into it. Out of our group of sixteen, four of my colleagues are on the heart team. Our few CRNAs aren’t involved in any hearts. We do about 250 cases a year. Those four get paid more, mostly for taking the extra call (although very, very rarely get called in for off-hour hearts). They don’t really end up working more hours than anyone else. Works fine for us.

 

[D P356]

Staffing may not be the only shots this dude is trying to call. Just wait until you’re coming off pump....

If he’s truly world renowned in CT surgery (the majority would say they are) he will have to prove it.

I enjoyed cardiac cases, but I’m glad I don’t presently have to deal with this.

 

[sevoflurane]

Unless there is a skillset or personality conflict, this NEW CT surgeon can go F himself. He has ZERO business trying to tell your group how to staff it. What happens at 1am when a type A comes in? You going to ask the non-call ct anes guy on his special list to come in? So arrogant. Tell your chief of CT to grow some balls. If he is new, he likely has a lot to learn still.

* referring to the new CT surgeon.

I have done this long enough to know that often times the surgeons that demand the most are the ones that need the most help.

 

[GassYous]

Probably to set up the room

That's the tech's job. CRNAs are superfluous and don't belong in the heart room.

* referring to the new CT surgeon.

I have done this long enough to know that often times the surgeons that demand the most are the ones that need the most help.

So true. Never fails.

 

[secretasianman]

So the other surgeons catch wind and demand their own strike teams. Then what?

 

[dchz]

So the other surgeons catch wind and demand their own strike teams. Then what?

Patient outcome improves? I'm honestly surprised this is not the norm. Every place i've done a CPB case (n=6 so far) has a special circulator and scrub tech that do the heart rooms... If you put the egos aside this is about the ACT structure and how to make $. The surgeon's request isn't ridiculous imo.

Staffing may not be the only shots this dude is trying to call. Just wait until you’re coming off pump....

In some regions this is the norm, the surgeons in fellowship dictated the perfusionists rather than the anesthesiologists. It can be a bit condescending but I felt like the previous CT anes team really dropped the ball and it takes a while to repair relations and gain trust.

Pretty much does the whole case? W in the actual F. Weak departments like these make me sick and are largely the reason we are where we are.

I see it as an economic problem rather than a cultural problem. Which can be said of our current situation as well.

Look at this job posting, it's endorsed as one of the best groups but it's 3:1 CRNA supervision. if you think CRNAs aren't doing the entire cases, you're naive.

Profit sharing practice looking for General/Cardiac Anesthesiologists. Top 10% MGMA in Florida ! Starting @400, Low Covid census!

Anesthesiology Associates of Tallahassee (AAOT) is seeking a Board Certified/Board Eligible Anesthesiologist for a full-time position with in Tallahassee, Florida. This group provides anesthesia services at Tallahassee Memorial Hospital, Capital Regional Medical Center and several ASCs...

forums.studentdoctor.net

 

[secretasianman]

The “best lap chole surgeon west of Mississippi” comes to town, heard the ct surgeon gets his own team. Thinks he should get his own team too. Sure no problem?

 

[deleted126335]

The “best lap chole surgeon west of Mississippi” comes to town, heard the ct surgeon gets his own team. Thinks he should get his own team too. Sure no problem?

We will as soon as we can recruit a fellowship trained gall bladder anesthesiologist.

 

[deleted162650]

We will as soon as we can recruit a fellowship trained gall bladder anesthesiologist.

And they laughed at me when I did that fellowship . . .

 

[Twiggidy]

I think that surgeon has a point. These smaller close knit groups that work together all the time generally perform better than larger groups that work with each other only occasionally. If smooth seamless performance is the top priority, that is the best way to achieve it in my opinion. I think we’ve all seen it. Of course, there are other priorities and considerations in the OR. If I were having heart surgery, I would want a team that worked together all day every day for over a decade.

Exactly this response. There are a lot of emotional non-cardiac responses in the thread. I know of even orthopedic surgeons who want a small group to do their total joints because the entire team is on the same page and the patients do well. When cardiac surgeon goes well it's because the service is a well oiled machine and every member knows their role and is confident the other person is doing their role without someone looking over their shoulder. If this surgeon performs well with a small group of people they're comfortable with it's hard for me to argue with that request.

The issue would be how do you select the team because that could cause problems.

 

[Hork Bajir]

Some people look at gall bladder cases and think they’re all the same. There are so many layers of complexity to lap choleys that you don’t really appreciate until you do the fellowship

 

[GassYous]

We will as soon as we can recruit a fellowship trained gall bladder anesthesiologist.

If I could do healthy gallbladders all day I would have zero problem with this. I'll push all the icg they want.

 

[sevoflurane]

I see it as an economic problem rather than a cultural problem. Which can be said of our current situation as well.

Look at this job posting, it's endorsed as one of the best groups but it's 3:1 CRNA supervision. if you think CRNAs aren't doing the entire cases, you're naive.

That’s cute. You obviously missed my point. Just because it happens doesn’t mean it’s right. “Sitting and doing” are very different. Naive is the s***ty anesthesiologist that isn’t involved in a cardiac case- passively endorsing CRNA solo cardiac practices .

Furthermore, from an economic side of things a solo cardiac anesthesiologist can make just as much or more than a 3:1 ratio.

 

[sevoflurane]

Exactly this response. There are a lot of emotional non-cardiac responses in the thread. I know of even orthopedic surgeons who want a small group to do their total joints because the entire team is on the same page and the patients do well. When cardiac surgeon goes well it's because the service is a well oiled machine and every member knows their role and is confident the other person is doing their role without someone looking over their shoulder. If this surgeon performs well with a small group of people they're comfortable with it's hard for me to argue with that request.

The issue would be how do you select the team because that could cause problems.

Pick the right size team for 250 cases. Everyone should be interchangeable at all hours of the day. Not just day time hours. Anyone who works within a heart team knows that every person in that room is as important as the next and we have to function without hiccups. The exception is skillset and personality issues. Having a surgeon pick his “A” team segregates the rest of the group and may cause internal issues.

Say you are a freshly graduated CT anesthesiologist and you get teamed up with a slow cabg CT surgeon who redoes every other graft meanwhile your senior partner bangs out 2 MVR’s by 1:30pm with the “valve specialist”.

How would you feel then? What if you are compensated per pump run (like my previous group)?

There is a little more room for teaming up groups with say 750 pump case volumes and 6 cardiac guys.

Do what’s right for your group is the bottom line.

Demi-god personalities need to be put in check.

 

[Twiggidy]

Pick the right size team for 250 cases. Everyone should be interchangeable at all hours of the day. Not just day time hours. Anyone who works within a heart team knows that every person in that room is as important as the next and we have to function without hiccups. The exception is skillset and personality issues. Having a surgeon pick his “A” team segregates the rest of the group and may cause internal issues.

Say you are a freshly graduated CT anesthesiologist and you get teamed up with a slow cabg CT surgeon who redoes every other graft meanwhile your senior partner bangs out 2 MVR’s by 1:30pm with the “valve specialist”.

How would you feel then? What if you are compensated per pump run (like my previous group)?

There is a little more room for teaming up groups with say 750 pump case volumes and 6 cardiac guys.

Do what’s right for your group is the bottom line.

Demi-god personalities need to be put in check.

There are certainly factors at play as well . Where is the practice located? What’s the local competition? Is the surgeon independent or part of a large multi specialty practice. The group has to tread water in situations like this because we all know cv surgeons, especially good ones, don’t grow on trees. I’ve personally seen this play out and the easiest thing to go is keep the surgeon happy

 

[sevoflurane]

There are certainly factors at play as well . Where is the practice located? What’s the local competition? Is the surgeon independent or part of a large multi specialty practice. The group has to tread water in situations like this because we all know cv surgeons, especially good ones, don’t grow on trees. I’ve personally seen this play out and the easiest thing to go is keep the surgeon happy

I hear you and if it works well for a particular practice so be it.

We have a very cohesive CT anesthesia/CT Surgeon group.

We go to their interview dinners, get CT surgeon CV’s prior to interviews and are part of their day in the OR- they do the same with our potential cardiac guys. We all discuss potential additions to the group. True team. Hang out in and outside of the hospital.... and of course have the occasional tough case together at 3am.

Works beautifully and is by far my favorite place to be in the hospital.

 

[deleted126335]

I hear you and if it works well for a particular practice so be it.

We have a very cohesive CT anesthesia/CT Surgeon group.

We go to their interview dinners, get CT surgeon CV’s prior to interviews and are part of their day in the OR- they do the same with our potential cardiac guys. We all discuss potential additions to the group. True team. Hang out in and outside of the hospital.... and of course have the occasional tough case together at 3am.

Works beautifully and is by far my favorite place to be in the hospital.

You are fortunate. This is rare.

 

[Twiggidy]

You are fortunate. This is rare.

Exactly. It’s not like that situation is the norm. Majority of us have to play the game

 

[ChiDO]

We have the same surgical staff for our total hips/knees 99.9% of the time (usually about same 6 rotating anesthesiologists) at the hospital. At the ASC, I have the same 2 anes and the same scrub staff everytime I'm there. My senior partner actually travels with 3 techs and they scrub at all 3 facilities with him. We can do about 6 totals by 12-1 at the ASC starting at 7 am. 6-8 totals by 5 PM at the hospital.

 

[sevoflurane]

IDK. Is the norm of a CT anesthesiologist to be a subservient to a CT surgeon? We are 75 anesthesiologist strong (we have CT, regional, OB, Trauma, Neonate and ICU teams that are all interchangeable within their subspecialties), serve on all MECs, have multiple OR directors, have chief of staff or soon to be chief of staff at all the hospitals in town.

The culture in our community is that of mutual respect weather you are a PCP or a Neurosurgeon. Our practice isn’t perfect, but nobody is telling us how to staff our OR’s. If there is a skillset or personality issue we work through them or find a solution.

Every job I’ve ever applied to I have asked to sit through a pump run. I’ve definitely picked up on some not so nice CT surgeons. Immediate pass on those groups.

 

[dhb]

Probably that many people doing cardiac to spread out the call burden. You could do 250 with 1-3 guys but who wants to be on call q1-3?

 

[GassYous]

We have the same surgical staff for our total hips/knees 99.9% of the time (usually about same 6 rotating anesthesiologists) at the hospital. At the ASC, I have the same 2 anes and the same scrub staff everytime I'm there. My senior partner actually travels with 3 techs and they scrub at all 3 facilities with him. We can do about 6 totals by 12-1 at the ASC starting at 7 am. 6-8 totals by 5 PM at the hospital.

I feel like that depends more on the surgeon than the anesthesiologist. I'm not a total joints all the time guy but I can have the spinal and 2 blocks done within ten minutes.

 

[nimbus]

I feel like that depends more on the surgeon than the anesthesiologist. I'm not a total joints all the time guy but I can have the spinal and 2 blocks done within ten minutes.

And SPD, and the scrubs, and preop, and the circulators. One weak link will gunk up the works.

 

[Twiggidy]

IDK. Is the norm of a CT anesthesiologist to be a subservient to a CT surgeon? We are 75 anesthesiologist strong (we have CT, regional, OB, Trauma, Neonate and ICU teams that are all interchangeable within their subspecialties), serve on all MECs, have multiple OR directors, have chief of staff or soon to be chief of staff at all the hospitals in town.

The culture in our community is that of mutual respect weather you are a PCP or a Neurosurgeon. Our practice isn’t perfect, but nobody is telling us how to staff our OR’s. If there is a skillset or personality issue we work through them or find a solution.

Every job I’ve ever applied to I have asked to sit through a pump run. I’ve definitely picked up on some not so nice CT surgeons. Immediate pass on those groups.

I would venture to say you do have a special situation, and that's not meant as an attack. I'm sure you have a practice that many people would enjoy and a few on here probably have similar setups. Others just may be in places where things don't align that way. I wish things were universally the way you describe but in some areas, anesthesiologist are expendable while good surgeons are a diamond in the rough. I'll admit we have a handful of surgeons that we have to bend over backwards for because they bring the patients, which in turn bring the units. There are WAY too many hospitals in the area so if we don't play the game right, they will take their patients down the road. We can change personalities and I understand it just enables bad behavior, but again, it's not like surgeons are running off an assembly line. These hospitals will fire (deny privileges) to GOOD surgeons just because they don't play well in the sandbox.

The game is just different in different places. Sure I'd be offended as an experienced CT anesthesiologist who is generally pretty affable if I weren't invited to participate with the team, but I can't get 100% mad knowing surgeon wants to have a steady team with good outcomes. At that point, I would do my best to get on the surgeon's good side.